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UHS Green Plan 2025-2028

Description: Green Plan 2025 - 2028 Approved November 2025 Contents 1 Executive Summary 2 Introduction and Context 3 Organisational Vis
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Sustainability-and-Green-Plan/UHS-Green-Plan-2025-2028.pdf

Rehab directory submissions

Description: Organisation Dorset Brain Injury Service Contact Name John Burn Email Address John.burn@poole.nhs.uk Telephone 01202448070 Website Address Poole Hospital Long Fleet Road Poole Dorset Further Information Specialist (2a) inpatient rehab unit for patients with brain injury. Priority given to traumatic brain injury and younger patients with complex therapy needs. The service constitutes part of the Neurological Rehabilitation Service. Service provides specialist assessment, psychological interventions and management. Helping survivors and their families regain some quality of life through a wide range of services, e.g. Cognitive rehabilitation programmes, carer support, and community outreach. Services are provided to people with Brain Hampshire Hospitals NHS Foundation Trust- Clinical Health Psychology Service Samuel Bastone Samuel.bastone@hhft.nhs.uk 01962824351 www.hampshirehospitals.nhs.uk Royal Hampshire County Hospital Winchester SO22 5DG Headway Basingstoke Heather Jury hjury@headwaybasingstoke.org.u k 01256314969 www.headwaybasingstoke.org.uk Headway BasingstokeHeadway Place Basingstoke RG24 9SP Headway Dorset office@headwaydorest.org.uk 01202 606562 www.headwaydorset.org.uk Headway Dorset Unit 22, Albany Park Dorset BH17 7BX Injury, their family members, carers and interested professionals. Cognitive, physical and social rehabilitation programmes are provided to support recovery specifically improving selfesteem and confidence. Headway Isle of Wight Joy.headway@gmail.com In Construction Headway (National) Sue Gillard Sue.gillard@headway.org.uk 01159240800 0782685581 www.headway.org.uk Headway Isle of Wight c/o 17 Beachfield Road PO35 5TN Bradbury House Nottingham NG6 8SF Headway Portsmouth and SE Hampshire info@headwayportsmouth.org.uk 02392664972 www.headwayportsmouth.org.uk Twyford Avenue Portsmouth PO2 9QA Headway provides a range of frontline services to help those affected by brain injury, including: A free phone helpline (0808 800 2244) and email, a comprehensive website. Local centre-based and outreach services are provided by Headway groups across the region. Helping survivors and their families regain some quality of life through a wide range of services e.g. Cognitive rehabilitation programmes, carer support, social reintegration. Headway Salisbury and South Wiltshire Headway Southampton Info@headwaysalsibury.co.uk 07725827869 www.salisburyheadway.co.uk Fountain Way Salisbury SP2 7FD 120 Commercial Road Totton SO40 3AD St Mary's Hospital Newport Isle of Wight PO30 5TG manager@headwaysouthampton.org.uk 02380862948 www.headway-southampton.org.uk Isle of Wight NHS TrustThe Rehabilitation Unit Mehran Maanoosi Mehran.maanoosi@iow.nhs.uk 01983524081 www.iow.nhs.uk Traumatic and other categories of Brain Injured patients excluding stroke perhaps occupying 56 beds out of 26 beds. Multiple injuries following Road Traffic accidents, sporting injuries, falls. Rehabilitation of patients with various neurological conditions. Phoenix Rehabilitation Mike Homer- Mike.homer- 02392283258 Queen Alexandra Centre (F1) Neurological Rehabilitation Portsmouth Prosthetic and Amputee Rehabilitation Service Ward ward@porthosp.nhs.uk Alison Hatfield Alison.hatfield@porthosp.nhs.uk Mike.homerward@porthosp.nhs.uk 02392680150 Hospital Portsmouth PO2 3LY Portsmouth Enablement Centre St Marys Community Health Campus PO3 6BR Salisbury NHS Foundation Trust- The duke of Cornwall Spinal Treatment Centre Wendy Slater Wendy.slater@salisbury.nhs.uk 01722336262 Salisbury District Hospital SP2 8BJ Solent NHS Trust- Solent Neurological Rehabilitation Services- Mary Vincent Mary.vincent@solent.nhs.uk 02380608031 www.solent.nhs.uk Adelaide Health Centre Millbrook This service provides outpatient rehabilitation to patients with congenital limb deficiency or acquired amputation from a range of cases including vascular/diabetes melitus, trauma or malignancy. Specialises in the total management of patients paralysed following spinal cord injury or nonprogressive spinal cord disease. The teams enable an individual to optimise their physical and psychological ability to achieve independence appropriate to their level of disability. Physiotherapists with a specialist interest in neurology and Community Neurological Rehabilitation Gym Southampton SO16 4XE Solent NHS Trust- Solent Neurological Rehabilitation ServicesCommunity Stroke Team Samantha Hemingway Samantha.hemingway1@solent.n hs.uk 07833401748 www.solent.nhs.uk Western Community Hospital Millbrook Southampton SO16 4XE Solent NHS Trust- Solent Neurological Rehabilitation ServicesNeuro Gym/Neurological Outpatient Physiotherapy Department Sally Ann Smith Sallyann.smith@solent.nhs.uk 02392286509 www.solent.nhs.uk Neuro Gym Physiotherapy Queen Alexandra Hosptial Portsmouth PO6 3LY Rehabilitation Assistants providing individual neurological assessment and treatment sessions. Promoting self management for people living with long term neurological conditions, working alongside other healthcare professionals. The community Stroke Team offer a specialist service to people over the age of 18 who have had a stroke. To support independence and improve quality of life by setting rehabilitation goals. Physiotherapists and technicians offering specialist adult neurological assessment and rehabilitation to people with neurological Solent NHS Trust- Solent Neurological Rehabilitation ServicesNeuropsychology East Jane McNeil Jane.mcneil@solent.nhs.uk 02392286000 www.solent.nhs.uk Neuropshycology department Queen Alexandra Hosptial PO6 3LY Solent NHS Trust- Solent Neurological Rehabilitation ServicesNeuropsychology West Jane McNeil Jane.mcneil@solent.nhs.uk 02380296273 www.solent.nhs.uk Western Community Hospital Southampton SO16 4XE conditions. Patients are assessed and personal treatment plans developed to work towards specific goals. Clinical psychologists who provide specialist assessment, rehabilitation and psychological therapy for the cognitive emotional and behavioural sequelae of Acquired Brain Injury. The service aims to minimise the negative effects, and maximise positive outcomes in terms of independence. Clinical psychologists who provide specialist assessment, rehabilitation and psychological therapy for the cognitive emotional and behavioural sequelae of Acquired Brain Injury. The service Solent NHS Trust- Solent Neurological Rehabilitation ServicesSnowdon at Home Samantha Hemingway Samantha.hemingway1@solent.n hs.uk 07788407076 www.solent.nhs.uk Western Community Hospital Southampton SO16 4XE Solent NHS Trust- Solent Neurological Rehabilitation ServicesSnowdon Neurological Rehabilitation Ward Sally-Ann Smith Sallyann.smith@solent.nhs.uk 07825733106 www.solent.nhs.uk Western Community Hospital Southampton SO16 4XE Solent NHS Trust- Solent Neurological Sally-Ann Smith Sallyann.smith@solent.nhs.uk 02380296222 www.solent.nhs.uk Western Community aims to minimise the negative effects, and maximise positive outcomes in terms of independence. A community neurological therapy team specialising in the treatment of people with a neurological diagnosis or symptoms such as head injury, multiple sclerosis, GuillainBarre Syndrome. Intensive rehabilitation in the home and community. A 14 bedded purpose built ward which specialises in the treatment of people with physical and cognitive limitations following a recent neurological event or a long term neurological condition. A registered nurse with additional Rehabilitation ServicesSpecialist Epilepsy Nurse Hospital Southampton SO16 4XE Solent NHS Trust- Solent Neurological Rehabilitation ServicesThe Kite Unit Tre Daughtery Tre.daughtery@solent.nhs.uk 02392684990 www.solent.nhs.uk The Kite Unit Nelson Drive St James Hospital Portsmouth PO4 8GD qualifications in supporting people with epilepsy provides a community service for adults with epilepsy. Supporting individuals to manage their epilepsy as best possible giving advice and guidance around seizures, treatment and lifestyle. A neuro psychiatric rehabilitation service for individuals with a brain injury whose impairments are largely in the cognitive, behavioural or mental health spectrum. Assessment, treatment and rehab for people requiring slow stream rehabilitation that may not be available from other services. Solent NHS Trust- Solent Neurological Rehabilitation ServicesTransition Therapy Team Sally-Ann Smith Sallyann.smith@solent.nhs.uk 02380296210 www.solent.nhs.uk Western Community Hospital Southampton SO16 4XE Solent NHS Trust- Solent Neurological Rehabilitation ServicesVocational Rehabilitation Service Sally-Ann Smith Sallyann.smith@solent.nhs.uk 02380716592 www.solent.nhs.uk Unit 12 9-19 Rose Road Southampton SO14 6TE Solent NHS Trust- Solent Neurological Rehabilitation ServicesCommunity Neurological Rehabilitation Team Sally-Ann Smith Sallyann.smith@solent.nhs.uk 02380296222 www.solent.nhs.uk Western Community Hospital Southampton SO16 4XE Offering occupational therapy and physiotherapy input to young people between the ages of 14-25 who have complex physical disabilities. The disabilities are predominantly neurological and some young people also have learning disabilities. This service can help people with neurological conditions identify the barriers that prevent them from returning to work. Provide treatment programmes with specific goals to help reduce or overcome those identified barriers. Specialising in the treatment of people with neurological conditions. The team consists of occupational UHS-Facial Rehabilitation Service WFNC@uhs.nhs.uk 02381203012 www.uhs.nhs.uk Therapy Department Southampton General Hospital SO16 6YD UHS- General Intensive Care/ Neurological Intensive Care Zoe Van Willigen Zoe.vanwilligen@uhs.nhs.uk Julie.buckley@uhs.nhs.uk 02381204184 www.uhs.nhs.uk Southampton General Hospital SO16 6YD therapists, physiotherapists, rehabilitation assistants, doctors, dieticians and speech and language therapists. The Wessex Facial Nerve Centre is a regional service dedicated to the treatment of facial nerve disorders and injuries. The Wessex Facial Nerve Centre brings together the skills, expertise and experience of a team of medical, surgical and rehabilitation specialists. All patients admitted to a critical care environment following Major Trauma will receive acute rehabilitation and early mobilisation as appropriate by specialist therapists. We have specialists in complex UHS- Lower Limb Amputee Rehabilitation Marie Hulse Marie.hulse@uhs.nhs.uk 02381203662 www.uhs.nhs.uk Small Gym, Therapies Department Southampton General Hospital SO16 6YD UHS- Orthopaedic Trauma Service- Musculoskeletal Inpatient Therapy Amanda Pike Amanda.pike@uhs.nhs.uk 02381204452 www.uhs.nhs.uk F Level Orthopaedics Southampton General Hospital SO16 6YD polytrauma, chest and thorax trauma, acute head and spinal injury. This service is provided on a Monday 10-1 and Thursday 10-2 with a band 7 specialist physiotherapist and a band 4 therapy technician. It is based in the small gym at UHS with access to early walking aidsPPAM aid and Femuret, parallel bars, balance equipment and multi-gym. The unit will accept and rehabilitate all forms of orthopaedic trauma, including Major Trauma patients. The orthopaedic therapy team offers a 7 day service covering 1 elective ward, 1 major trauma ward, 1 dementia friendly ward, 1 trauma ward, UHS- Musculoskeletal Outpatient Therapy Service Amanda Pike Amanda.pike@uhs.nhs.uk 02381206459 www.uhs.nhs.uk Therapy Department Southampton General Hospital SO16 6YD Wessex Rehabilitation Centre Peter Wareham Peter.wareham@salisbury.nhs.uk 01722336262 www.salisburu.nhs.uk/informationfor patients/departments/pages/wessexr ehab.aspx Musculoskeletal Rehabilitation Salisbury District Hospital Salisbury SP2 8BJ day surgery and 1 step down care ward. The outpatient musculoskeletal service is a MonFriday 7.30-5.30 service and accepts referrals from UHS Consultants. Service takes various musculo-skeletal injured patients who are not progressing as expected, or need more input than can be provided, by outpatient services. Service includes physiotherapy, occupational therapy, nursing and consultant input.
Url: /Media/SUHTExtranet/WessexTraumaNetwork/Rehab-directory-submissions.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
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/quality-account-24-25-final1.pdf

Papers CoG 29.04.2025 v2

Description: Date Time Location Chair Agenda Council of Governors 29/04/2025 14:00 - 15:45 Conference Room, Heartbeat/Microsoft Teams Jenni
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-29.04.2025-v2.pdf

Annual-report-24-25-final

Description: 2024/25 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2024/25 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2025 University Hospital Southampton NHS Foundation Trust Contents Welcome from our Chair and Chief Executive 7 Performance report 9 Introduction from the Chief Executive 10 Overview 11 Principal risks to our strategy and objectives 16 Performance overview 17 Performance analysis 22 Quality priorities 29 Financial performance 33 Sustainability 33 Social, community, anti-bribery and human rights issues 34 Events since the end of the financial year 35 Overseas operations 35 Equality in service delivery 35 Going concern 41 Accountability report 42 Directors’ report 43 Remuneration report 69 Staff report 82 Counter fraud 98 Code of governance for NHS provider trusts 98 NHS System Oversight Framework 99 Statement of the chief executive officer’s responsibilities as the accounting officer of UHS 100 Annual Governance Statement 102 Scope of responsibility 102 The purpose of the system of internal control 102 Risk management and control within the Trust 102 Review of economy, efficiency and effectiveness of the use of resources 116 Quality account 119 Part 1: Statement on quality from the Chief Executive 120 Part 2: Priorities for improvement and statements of assurance from the Board 122 Part 3: Other information 194 5 Annual accounts 241 Statement from the Chief Financial Officer 242 Auditor’s report including certificate 244 Foreword to the accounts 251 Statement of Comprehensive Income 252 Statement of Financial Position 253 Statement of Changes in Taxpayers’ Equity 254 Statement of Cash Flows 256 Notes to the accounts 257 6 Welcome from the Chair and Chief Executive Officer University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) has experienced another challenging year, with increased demand for the Trust’s services, a more restrictive financial environment, and changes in terms of the organisation of the NHS in England. Despite the challenges faced by the Trust during 2024/25, we can feel incredibly proud of the achievements of our 13,000 staff, who went above and beyond to deliver for our patients and the communities we serve. Particular highlights include: • In the top 15 in the country against government targets for elective recovery performance with 127% of activity compared with 2019/20. • Top-quartile performance against most performance metrics compared to similar sized teaching hospitals, including long-waiting patients on referral to treatment pathways, diagnostics and cancer performance. • Delivery of £85.3m of savings through our cost improvement programme – the highest ever amount by the Trust. We continue to be one of the best performing trusts in England in many areas. The Trust’s elective recovery performance places it as one of the best performing trusts in England. As a result, we have seen the number of long-waiting patients fall to one patient waiting over 78 weeks and to 21 patients waiting over 65 weeks – in many instances these delays were due to a national lack of corneal transplant tissue. This is despite an increase in the number of patients being referred to the Trust for treatment. Our performance against key cancer metrics has seen an improvement in commencing treatment of cancer within 62 days to 81% by March 2025, against the NHS England average for 2024/25 of 70.5%. Similarly, the Trust performed in the range of 88%-96% during the year against the target of patients commencing treatment within 31 days of diagnosis. There has been significant demand for non-elective care throughout the year, which has placed significant demands on the Trust’s emergency department. There were frequently more than 400 attendances per day and the Trust saw an average of 13,100 patients per month (2023/24: 12,700). As a result of this increased demand, coupled with issues with flow through the hospital and a high incidence of seasonal illnesses during the winter, UHS’s performance against the four-hour emergency department target has steadily declined over the course of 2024/25. The Trust also recorded a lower than expected death rate via the Summary Hospital-level Mortality Indicator (SHMI) and was one of 12 trusts in England out of 119 with lower than expected death outcomes. The Trust reported a deficit of £7m at year-end, which represents a significant achievement given the financial pressures we have experienced, such as significant demand for services above block contract levels, pay award pressures, and inflation. The Trust also saw its productivity improve during the year and delivered its highest ever performance under its cost improvement programme. 7 Despite the introduction of strict controls in early 2024, the Trust exceeded its target for workforce numbers during 2024/25 by 373 whole-time-equivalents. However, a significant proportion of this number was due to assumed reductions in the number of staff required to manage patients with no clinical criteria to reside in the hospital and patients with a primary mental health need not materialising. Instead, the number of both categories of patient continued to rise during the year, placing additional strain on the Trust’s capacity and reducing flow through the hospital as patients are unable to move in a timely way from the emergency department, to wards and then to discharge due to lack of capacity. Higher levels of staff absence during the winter months coupled with high levels of seasonal illness and consequent demand on the emergency department also necessitated the opening and staffing of surge capacity. Indeed, demand on the emergency department was so great during the year that surge capacity was required even outside of the typically busier winter period. Our people remain our greatest asset. Without our staff, the Trust would not be able to deliver for the communities we serve. We were pleased to see the results from the 2024 Staff Survey, which placed UHS above the benchmarking group across all the key people themes. In particular, there have been improvements in relation to satisfaction with immediate managers, flexible working opportunities, and staff recommending UHS as a place to work. UHS has also continued with its staff room refurbishment programme and made significant improvements to the prayer facilities for Muslim staff, patients, students and community members in our chapel, all funded by Southampton Hospitals Charity. We expect 2025/26 to be even more challenging than 2024/25. The Trust has already had to take some difficult decisions in terms of its workforce numbers, prioritisation for capital expenditure, and services. We will be expected to continue to maintain quality of patient care and experience and to deliver the required levels of performance whilst at the same time having to make significant reductions in its expenditure to deliver a balanced budget. Many of the challenges faced by the Trust – in common with other providers – can only be addressed by working in partnership with wider local partners, such as other healthcare providers, local authorities and charities to deliver system-wide solutions. At the same time, we recognise that there is more that we can do internally to ensure that our internal processes deliver in the most effective and efficient manner. We would like to express our heartfelt thanks to our amazing staff, who have gone and continue to go above and beyond to put our patients first and deliver world class care. Jenni Douglas-Todd Chair David French Chief Executive Officer 8 PERFORMANCE REPORT OVERVIEW AND PERFORMANCE Performance report Introduction from the Chief Executive Officer This was another challenging year for the Trust, continuing the trend seen in previous years of increasing demand which must be balanced with the need to deliver quality patient care whilst maintaining a sustainable financial position. The Trust saw even higher demand for non-elective care than in recent years with attendances at the emergency department being as high as 400 per day and the Trust having to open and staff surge capacity for a significant proportion of the year, including outside of the typically more strained winter period. The trend of increasing numbers of patients having no clinical criteria to reside in hospital, but unable to be discharged due to a lack of funded care in a more appropriate venue, continued, as did the increasing number of patients presenting with a primary mental health need. This placed significant pressure on the Trust’s resources due to the impact on flow through the hospital and the need to engage additional members of staff to manage these patients – in some instances this requires as many as four members of staff, usually via a specialist agency, for each patient as well as, potentially, additional security resource. Despite the challenges, the Trust continued to perform well when compared to other comparable organisations, achieving some of the best elective recovery performance in England at 127% compared to 2019/20 levels. The Trust implemented spending and recruitment controls in early 2024, which it continued to operate under during 2024/25, in order to manage its difficult financial position. However, the Trust ended the year above its plan in terms of workforce numbers, although a significant proportion of this amount was due to the increasing number of patients having no criteria to reside and mental health patients. The Trust achieved its highest ever delivery on its cost improvement programme with £85.3m of savings, and achieved an overall end of year deficit of £7m. 10 OVERVIEW AND PERFORMANCE Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of £1.5 billion in 2024/25. It is based on the coast in southeast England and provides services to people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to nearly four million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and one of the top nationally for research study volumes as ranked by the NIHR Clinical Research Network. Every year the Trust: treats around 166,000 inpatients and day patients, including about 75,000 emergency admissions sees over 770,000 people at outpatient appointments deals with around 155,000 cases in its emergency department The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care, and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton, it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff, it acts as a community midwifery hub. • Lymington New Forest Hospital – a community hospital located in Lymington managed by Hampshire and Isle of Wight Healthcare NHS Foundation Trust. UHS manages surgical services at the hospital. The services provided by the Trust are commissioned and paid for by the Hampshire and Isle of Wight Integrated Care System (ICS) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. 11 OVERVIEW AND PERFORMANCE Trust services are supported by clinical income, of which 53% is paid for by NHS England and 44% by integrated care boards, predominantly the Hampshire and Isle of Wight Integrated Care Board (ICB). These are provided under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by NHS England and the healthcare services we provide are regulated by the Care Quality Commission. Since 1 July 2022, the Trust has been part of the Hampshire and Isle of Wight Integrated Care System when this was established through the Health and Social Care Act 2022. Each ICS has two statutory elements: an integrated care partnership (ICP) and an integrated care board. The ICP is a statutory committee jointly formed between the NHS integrated care board and all upper-tier local authorities that fall within the ICS area. The ICP brings together a broad alliance of partners concerned with improving the care, health, and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area. The ICB is a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Public and foundation trust members Council of Governors Board of Directors Executive Directors Division A Surgery Critical Care Ophthalmology Theatres and Anaesthetics Division B Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Division C Women and Newborn Maternity Child Health Clinical Support 12 Division D Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Trust headquarters division OVERVIEW AND PERFORMANCE Our values The Trust’s values describe how things are done at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. These values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 13 OVERVIEW AND PERFORMANCE Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything its staff had experienced during the COVID-19 pandemic and what had been learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. The Trust’s strategy is organised around five themes and for each of these it describes a number of ambitions UHS aims to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • experience and safety By 2025 we will strengthen our national reputation for outstanding • patient outcomes, experience and safety, providing high quality care • and treatment across an extensive range of services from foetal medicine, through all life stages and conditions, to end-of-life care. Pioneering research and • innovation We will continue to be a leading • teaching hospital with a growing, reputable and innovative research • and development portfolio that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • Supporting and nurturing our people through a culture that values • diversity and builds knowledge and skills to ensure everyone reaches their full potential. We must provide • rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and • collaboration We will deliver our services with • partners through clinical networks, collaboration and integration across geographical and organisational • boundaries. • We will monitor clinical outcomes, safety and experience of our patients regularly to ensure they are amongst the best in the UK and the world. We will reduce harm, learning from all incidents through our proactive patient safety culture. We will ensure all patients and relatives have a positive experience of our care, as a result of the environment created by our people and our facilities. We will recruit and enable people to deliver pioneering research in Southampton. We will optimise access to clinical research studies for our patients. We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. We will recruit and develop enough people with the right knowledge and skills to meet the needs of our patients. We will provide satisfying and fulfilling roles, growing our talent through development and opportunity for progression. We will empower our people, embracing diversity and embedding compassion, inclusion and equity of opportunity. We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated Care System. We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 14 OVERVIEW AND PERFORMANCE Foundations for the future • We will deliver best value to the taxpayer as a financially Making our enabling infrastructure efficient and sustainable organisation. (finance, digital, estate) fit for • We will support patient self-management and seamless the future to support a leading care across organisational boundaries through our university teaching hospital in the ambitious digital programme, including real time data 21st century and recognising our reporting, to inform our care. responsibility as a major employer • We will expand and improve our estate, increasing in the community of Southampton capacity where needed and providing modern facilities and our role in broader for our patients and our people. environmental sustainability. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2024/25 these objectives included: Outstanding patient Establishing an integrated approach to quality management. outcomes, experience Treating patients according to need but aiming to meet the target of zero and safety 65-week waiters by the end of September 2024, and continued reduction of longer waiters. Reducing length of stay across elective and non-elective pathways. Improving patient experience and outcomes through continued implementation of the Fundamentals of Care programme. Pioneering research and innovation Delivering year four of the research and innovation investment plan. Delivering year two of the five-year research and development strategy implementation plan for research for impact. World class people Delivering a workforce plan for the Trust for 2024/25 which is safe, sustainable and affordable. Delivering targeted improvements in staff experience, engagement and culture. Sustaining turnover at less than 13% and maintaining sickness absence at under 4%. Integrated networks In partnership with acute trusts working directly with priority areas to and collaboration progress joint network strategies. Working with the local delivery system on vertical integration to reduce the number of patients without criteria to reside. Foundations for the future Delivering a stretching financial plan for 2024/25, including identifying what needs to be true to recover a sustainable financial position and exit the Recovery Support Programme. Engaging the organisation in the challenge to manage demand so that capacity and demand are in equilibrium. Delivering the aims of the 2024/25 transformation programmes and always improving strategic priorities. Delivering the prioritised 2024/25 capital programme and setting a prioritised capital programme for 2025/26. Completing year two of the Public Sector Decarbonisation Scheme. 15 OVERVIEW AND PERFORMANCE Performance against these objectives was monitored and reported to the Trust’s Board on a quarterly basis. At the end of 2024/25, the Trust had met the objectives set as follows: Corporate Ambition Number of Green Amber Red objectives Outstanding patient outcomes, 4 3 1 0 safety and experience Pioneering research and innovation 2 2 0 0 World class people 3 2 0 0 Integrated networks and collaboration 2 0 2 0 Foundations for the future 5 2 2 1 Totals 16 8 6 2 Note: Green: achieved in full Amber: partially achieved Red: not achieved Particular areas to highlight where the Trust has achieved strong delivery during the year include: • Reduction in the number of patients waiting over 65 weeks, with only 21 waiting over 65 weeks. • Reduction in the length of stay by 5.25% through successful delivery of the inpatient flow transformation programme. • Implementation of the Fundamentals of Care programme. • Successful delivery of year four of the research and innovation investment plan. • Reducing staff turnover to 10.1% at year end and achieving a staff absence rate below 4%. • Progress in developing the identified priority clinical networks. • Successful delivery of the Trust’s 2024/25 capital programme. Principal risks to our strategy and objectives The Board has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2024/25 were that: • There would be a lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. • Due to the current challenges, the Trust fails to provide patients and their families or carers with a high-quality experience of care and positive patient outcomes. • The Trust would not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. • The Trust does not take full advantage of its position as a leading university teaching hospital with a growing, reputable and innovative research and development portfolio, attracting the best 16 OVERVIEW AND PERFORMANCE staff and efficiently delivering the best possible treatments and care for its patients. • The Trust is unable to meet current and planned service requirements due to unavailability of staff to fulfil key roles. • The Trust fails to develop a diverse, compassionate and inclusive workforce, providing a more positive experience for all staff. • The Trust fails to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. • The Trust does not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • The Trust is unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme; NHS England imposing additional controls/ undertakings; and a reducing cash balance, impacting the Trust’s ability to invest in line with its capital plan, estates and digital strategies and in transformation initiatives. • The Trust does not adequately maintain, improve and develop its estate to deliver its clinical services and increase capacity. • The Trust fails to introduce and implement new technology and expand the use of existing technology to transform its delivery of care through the funding and delivery of the digital strategy. • The Trust fails to prioritise green initiatives to deliver a trajectory that will reduce its direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. As in previous years, demand for services continued to increase, especially for emergency (nonelective) care. The winter months in particular saw both high levels of demand and above average levels of staff absence due to seasonal illnesses. The Trust consistently experienced high numbers of patients having no clinical criteria to reside in hospital, but who could not be discharged due to a lack of appropriate care packages. This results in a lack of flow through the hospital and also requires additional staff to be engaged due to the need to open surge capacity. In addition, the Trust continued to experience significant challenges from patients with a primary mental health care need for whom there were insufficient spaces available in a more suitable alternative setting. Performance overview The Trust monitors a broad range of key performance indicators within its departments, divisions, directorates and through Trust executive committees. On a monthly basis, the Board and executive committee receives a performance report containing a variety of indicators intended to provide assurance in respect of the Trust’s strategy and that the care provided is safe, caring, effective, responsive, and well-led. This report also includes the Trust’s performance against the national targets set by NHS England. The performance reports include a ‘spotlight’ section, which provides more detailed analysis of a particular area. Typically, this is one of either the national targets or the Trust’s performance against the expectations set out in the NHS Constitution. 17 OVERVIEW AND PERFORMANCE The monthly performance report is also published on the Trust’s website. The Chief Executive Officer provides a regular report on performance to the Council of Governors, which includes a range of non-financial and financial performance information. Capacity The Trust experienced high demand for its services, continuing the trend from previous years. Demand in the emergency department in particular was significant, with attendances growing by 3.2% compared to 2023/24. This situation has resulted in a gradual decline in the Trust’s performance against the target of 95% patients spending less than four hours in the main emergency department. The number of patients having no clinical criteria to reside continued to impact flow within the hospital. The number of patients having no clinical criteria to reside was frequently above 250 at any one time during the year. The Trust experienced an increase in the number of referrals with the number of patients on a waiting list under the 18-week referral to treatment pathway rising from approximately 59,000 to 62,000 by the end of the year. Quality and compliance The Trust’s elective recovery performance was one of the best in England at 127% compared to 2019/20. The Trust continued to monitor the quality of care delivered throughout 2024/25 through a number of established quality assurance programmes. Clinical leaders monitored key quality, safety and patient experience indicators such as falls, pressure ulcers and venous thromboembolisms. The roll out of the Trust’s Fundamentals of Care initiative continued. High-quality peer reviews were consistently conducted, with a key focus on weekly matron-led quality walkabouts – both during and outside of standard hours – centred around the five CQC domains: safe, effective, responsive, caring, and well-led. Additionally, focused matron walkabouts were introduced to address specific themes related to patient safety and Fundamentals of Care standards, such as medication safety and infection prevention. These initiatives have been instrumental in identifying areas for improvement and promoting the sharing of best practices across teams. The Trust’s clinical accreditation scheme (CAS) builds on this intelligence, with clinical areas completing self-assessments of performance and review teams completing on-site visits. The clinical areas were supported by the CAS team from an initial contact meeting and walkabout through to outcome panel. Patient representatives were included in these review teams. CAS paperwork was reviewed to reflect the learning points from themed Matron’s walkabouts, aligning it to the CQC single assessment framework and the UHS Fundamentals of Care programme to ensure a robust ward accreditation. Learning was shared at the clinical leaders’ group and via reports. 18 OVERVIEW AND PERFORMANCE A framework was developed to govern Mortality and Morbidity meetings at the Trust, setting expectations for the content and format of these meetings. In addition, further work was carried out to ensure that the output from these meetings was shared more widely and that there is a clear escalation process. The Trust opened a patient and family support hub, repurposing the Macmillan Centre into a generic non-disease specific facility. The Trust worked with system partners to develop a unified and standardised approach to volunteer recruitment using a passporting system. The Trust commenced its implementation of the National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). Violence, abuse and aggression against staff continued to rise. The Trust took action over the course of the year to support its teams, including through roll out of de-escalation training. This has had a positive impact and has reduced the requirement for physical restraint and has reduced the number of incidences of physical violence against staff. However, the level of violence and aggression directed at staff by patients and other members of the public continues to be an area of concern for the Trust. The Trust continued to build its always improving culture and drive on quality improvement by training over 1,000 staff, remaining 3% above the NHS average for all improvement focussed staff survey questions and winning an award for patient involvement in improvement and safety. This enabled improvements across theatre, inpatient flow and outpatient programmes. In 2024/25, average length of stay was reduced by 5.25%, an additional 1,230 patients were treated in theatres, and 7% of patients were placed onto patient initiated follow up (PIFU) outpatient pathways. Partnerships Further information can be found in the quality account. The Trust works within the Hampshire and Isle of Wight Integrated Care System and is an active member of a number of partner groups including the Acute Provider Collaborative Board and the Health and Wellbeing Board. The Trust develops and agrees its annual financial plans with the Integrated Care Board. The Trust is a member of a number of specific partnership groups for particular services, including the Central and South Genomics Medicine Service, the Children’s Hospital Alliance and the Southern Counties Pathology Network. The Trust works actively as a partner with other provider organisations around clinical networks, particularly with acute Trusts within the Integrated Care System and others closely located geographically. The Trust also links closely with the University of Southampton on a number of topics including research, commercial development and education and has a developed meeting structure to oversee this. 19 OVERVIEW AND PERFORMANCE Workforce The Trust’s key area of focus during 2024/25 was to maintain a flat workforce level in order to meet the Trust’s 2024/25 workforce plan. In addition, the Trust sought to reduce reliance on bank and agency staff. The Trust ended the year above its workforce plan by 373 whole-timeequivalents. A significant proportion of the expected reduction in staff numbers had been linked to expected delivery of reductions in the number of patients having no criteria to reside and mental health patients through system-wide transformation programmes. However, these reductions did not materialise. In addition, due to the significant demand on the Trust’s services, it was necessary to open and staff surge capacity. This was exacerbated by high levels of staff absence due to illness during the winter months. The Trust was successful in reducing staff turnover to 10.1%, achieving the local target of 75% of staff in each area has received training, including neonatal medical team. • Trolley dashes. • Train the trainer. Progress metrics Audit of compliance: • Has it been undertaken for the appropriate babies? • Was the frequency of observation undertaken correctly? • Was the score accurately calculated? • Did escalation take place if required? • Was the response to escalation appropriate? 157 QUALITY ACCOUNT Quality Improvement Priority Four: Implementation of the National Safety Standards for Invasive Procedures (NatSSIPs) 2 at UHS Core dimension Patient safety Rationale of selection The new National Safety Standards for Invasive Procedures (NatSSIPs 2) represent the progression of the original NatSSIPs. The key aim to standardise, harmonise and educate (SHE) across organisations and procedural teams remains central to the NatSSIPs purpose. Critical changes include bolstered organisational standards and proportionate checks that recognise different levels of risk during major and minor invasive procedures, and the adaptions to processes that may be necessary in lifethreatening situations. This standardisation, harmonisation and education goals are set out in the table below. Standardise Harmonise Educate Organisational Sequential (‘The NatSSIPs Eight’) Safety behaviours, processs, policies, insight, involvement and performance measures across organisations and specialities. Expected behaviour, safety standards, checklists and format across invasive specialities. Across groups of hospitals. Across IT systems. Reduce variation across specialities. Commit to safety education, human factors expertise and systems thinking. Create a safety infrastructure, leadership understanding and training in cultural change. Teach and train in team behaviours, human factors, systems thinking learning / co-production with patients. Investigations into the increase of never events in 2023 and 2024 has identified that the majority of these had contributing factors related to stop points for safety. The key learning identified: Thematic analysis of never events Surgical mark not visible/clear Not listening to patient concerns Change in surgical plan and lack of documentaion Lack of time out if concerns are raised Lack of triangulated checks Ability to speak up concerns Swab, sharp and instrument count process Implant checks not triangulating patent details Inexperienced staff with lack of familiarity of processs Lack of induction training in stop points Distractions during stop point checks 158 QUALITY ACCOUNT All these factors will be addressed through NatSSIPs2 implementation. Safer invasive procedures is to be included as a local quality indicator by the ICB within the 2025/26 national contract. Key aims • Establish a NatSSIPs oversight committee. • Set up an invasive procedures committee. • Establish the following workstreams: o Audit of stops point for safety in theatres and for minor procedures in outpatient and ward areas o Multi-disciplinary safety walkabouts o VLE and induction workstream • Education: recruitment of medical education led to set up simulation-based MDT training. • Patient involvement. • NatSSIPs eight and communications. • Stop points for safety staff resources. Progress metrics • Increase in the completion of VLE stop points training. • Develop and implement a programme to deliver non-technical skills to the MDT. • All areas with a never event in the last two years have an up to date audit and action plan for compliance with NatSSIPs2. 159 QUALITY ACCOUNT Quality Improvement Priority Five: Fundamentals of Care Core dimension Patient safety Rationale of selection The term Fundamentals of Care (FoC) describes the eight standards that staff across the Trust have committed to in collaboration with the patient, to support the physical and emotional needs of patients’, relatives, and carers. This is not a new concept, it underpins the core values of what it means to be a healthcare professional, to truly ‘care’ and will build upon our achievements in year one. Operational challenges have led the workforce to become more task-focused and less personfocused, taking away from that personalised care experience but we are committed to changing that culture, following our Trust value, patients first. The FoC exemplifies how the interdisciplinary team connects and builds relationships with our patients, getting to know them and what matters to them as a person, not just as a patient, supporting and encouraging independence and rehabilitation from the beginning of their hospital stay. These activities are the essentials of our daily living such as personal hygiene, skin care, oral hygiene, toileting, eating and drinking, and mobilising. Communication is also essential and includes both listening and hearing patients, understanding what is important to them using communication tools they need, coming to shared decisions with patients about their care and recognising the diversity of our population, embracing accessibility for those with people with learning disabilities, sight/hearing loss or other disabilities, or if English may not be their primary language. In addition, the FoC encourages us as healthcare professionals to consider the whole person, support cultural, spiritual, mental health, emotional wellbeing and dignity needs of people we care for and those that matter to them. We know here at UHS that not everyone experiences this level of care, but we acknowledge the need to change the rhetoric from ‘we are busy’ to ‘we are never too busy to care’ empowering and educating our staff at all levels to challenge the ‘we have not got time’ rhetoric and ensure fundamental care is at the heart of what we do at UHS. Thus improving, patient care and experience. Key aims We will grow the multi-disciplinary engagement and involvement in workstreams that embrace the FoC and encourage person centred to care. We will continue to pursue the digitalisation of the Friends and Family Test (FFT), using this data and the national inpatient and urgent and emergency care survey as a baseline, while linking with involved patients where required with to encourage feedback on the FoC. We will listen to the voice of our patients, their relatives, and carers to make sure their stories and experiences are heard by our workforce to encourage the organisation wide change. We will ensure the FoC will has clear and measurable improvement metrics as part of a live clinical quality dashboard that will afford ward managers and senior leaders, the opportunity to monitor, review and report on to FoC in their areas. 160 QUALITY ACCOUNT We will embed the FoC into the matron walkabout and CAS processes, supported by consistent evaluation metrics that ask the patients about their experiences and encourage clinical areas to continually assess and evaluate the FoC in their areas through a self-assessment tool. We will enhance the availability of existing resources on our virtual learning environment (VLE) in collaboration with our patient partners for all staff groups and embed the FoC into training across the organisation, to improve the knowledge, skills and awareness ensuring the delivery of quality care. We will continue to test and evaluate the What Matters To Me project, growing our volunteer role to support staff in finding out what is important to the patient and using their personalised board to remind staff of the ‘person’ they are caring for. We will continue to establish project links in child health, maternity and outpatients to ensure a bespoke, but collaborative roll out of FoC, considering how these different care environments may impact care. Progress metrics • Patient hygiene: we will see an improvement in the number of patients who report having their personal care needs met, particularly within their first 24 hours coming through emergency admission routes. • Skin integrity: we will support the reduction in incidences of avoidable pressure ulcers across the organisation. • Communication: we see an increase in the number of people accessing our interpreting services and a reduction in complaints related to interpretation. • Pain: we will see an improvement in patients reporting that their pain was well controlled when coming through the emergency department. • Mouthcare: we will see a positive uptake in the implementation of the new mouthcare assessment tool and an improvement in patients reporting that their oral hygiene needs have been met. • Nutrition and hydration: we will see an increase in patients reporting they are being offered adequate food and drink provisions throughout their hospital stay, including access to equipment for those with conditions or disabilities that impact their ability to do so independently. • Bowel and bladder care: we will see improved assessment of bowel and bladder habits through increased documentation using the Inpatient Noting system. • Enhancing safe movement: we will support a reduction in the incidence of high harm falls and high harm falls that have preventable causes. • Infection prevention: we will see a reduction in nosocomial infections through increased hand hygiene standards and more effective cleaning of equipment. 161 QUALITY ACCOUNT Quality Improvement Priority Six: Develop the Trusts’ approach to reducing the impact of health inequalities (HIs) (year two) Core dimension Clinical effectiveness Rationale of selection Tackling health inequalities is a key priority for the NHS. At UHS we have been working to have an impact on health inequalities for several years. In 2024/25 we formalised these efforts with a governing board, chaired by our chief medical officer and with a clear programme of improvement based on recognised priorities. This formed the basis of our quality priority in 2024/25. This year’s quality priority is a continuation of the work that started in 2024/25. We intend to continue to grow our understanding and actions as an organisation, improving the equity of access, outcomes and experience of our services across our community. Key aims We are continuing our health inequalities board, with focus on five priorities: enabling our organisation, data and measurement, clinical service priorities, communication and engagement and strategy and approach. Each of these priorities have aligned directors to oversee improvement and a detailed delivery plan. Key priorities and expected outcomes from each of these are listed below: Enabling the organisation • Developing supporting structures: set up governance so that teams who identify health inequality related issues know where they can go for help, so that we can understand frequently arising challenges and notice when a problem raised might be affecting other of the hospital too. This will aid improvement, learning from issues identified and escalation of issues that cannot be resolved locally • Capability building: develop training for our staff to understand health inequalities, identify them within services and access tools to make improvement. • Delivery of the health inequalities officer role: grow knowledge of the health inequalities officer role across the organisation and utilise this role to share knowledge, training and support improvements. Data and measurement • Continue to develop our understanding of inequalities in access across outpatients and diagnostics, inpatients, theatres and the emergency department. • Enable the measurement of improvement in areas recognised as clinical priorities. • Enable completion of national reporting. Clinical priorities • Improve services and support for patients and staff with obesity (children and adults). • Improve identification and control of hypertension. • Improve services and support for patients and staff who smoke. 162 QUALITY ACCOUNT Communication and engagement • Adopt health inequalities into leadership and decision making. • Learning from our communities and our staff. • Communicating improvements internally and externally. • Staff support campaign. Strategy and approach • Overseeing and agreeing UHS approach and strategy for HIs. • Overseeing annual delivery against priorities. • Aligning programme resource. • Maintaining collaborative working with public health and Integrated care board teams and other local healthcare providers. • Keeping up to date with national recommendations and expectations, sharing this knowledge with our organisation. • Overseeing trust-wide improvement and health inequalities maturity. Progress metrics • Increasing numbers of staff trained. • Numbers of health inequalities issues reported (expected to increase through understanding before reducing due to improvement work). • Case studies shared of successful improvement projects. • Increased involvement and collaboration with patients and public on improvement. • Increased use of QEIA templates in decision making. • Demonstration of improved access to care for obesity, tobacco dependency and hypertension. 163 QUALITY ACCOUNT 2.3 Statements of assurance from the Board This section includes mandatory statements about the quality of services that we provide relating to the financial year 2024/25. This information is common to all quality accounts and can be used to compare our performance with that of other organisations. The statements are designed to provide assurance that the board of directors has reviewed and engaged in crosscutting initiatives which link strongly to quality improvement. 2.3.1 Review of services During 2024/25 UHS provided and/or sub-contracted 118 relevant health services (from total Trust activity by specialty cumulative 2024/25 contractual report). UHS has reviewed all the data available to them on the quality of care in all these relevant health services. The income generated by the relevant health services reviewed in 2024/25 represents 100% of the total income generated from the provision of relevant health services by UHS for 2024/25. 2.3.2 Participation in national clinical audits and confidential enquiries The UHS clinical audit programme was developed in support of the Trust’s vision by putting patients first, working together and always improving. This leads on to a specific strategy for clinical outcomes, to ensure robust and measurable processes are in place to plan locally and participate strategically. Healthcare Quality Improvement Partnership (HQIP) produces a National Clinical Audit & Enquiries Directory which identifies those national audits which are included in the NHS England Quality Account List 2024/25, those audits which are part of National Clinical Audit and Patient Outcomes Programme (NCAPOP). NCAPOP audits are commissioned and managed on behalf of NHS England by HQIP. These collect and analyse data supplied by local clinicians to provide a national picture of care standards for that specific condition. On a local level, NCAPOP audits provide local trusts with individual benchmarked reports on their compliance and performance, feeding back comparative findings to help participants identify necessary improvements for patients. The audits listed on the NCAPOP are ‘must-do’ national audits. The quality accounts national clinical audit list includes audits which we regard as ‘best practice’ to participate in (in addition to those from the NCAPOP) and for that reason we always include these in our corporate audit plans as a priority where they are relevant to our Trust. UHS has a strong history for completing clinical audits. The clinical effectiveness team has a robust approach to governing and supporting the completion. We’ve opened discussions with senior clinical leadership within Hampshire and Isle of Wight Integrated Care Board regarding the current challenges with contributing to and using the outputs of national audits. Benchmarked data resulting from national audits provides strong guidance on areas of excellence and improvement, however completion can be challenging in its compl
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-24-25-final.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 Jenni Douglas-Todd 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Staff Story The 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 29 September 2022 9:20 Approve the minutes of the previous meeting held on 29 September 2022 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 Charitable Funds Committee (Oral) 9:30 Dave Bennett, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:35 Jane Bailey, Chair 5.3 Briefing from the Chair of the Quality Committee (Oral) 9:40 Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:45 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Integrated Performance Report for Month 7 10:05 Review and discuss the Trust's performance as reported in the Integrated Performance Report. Sponsor: David French, Chief Executive Officer 5.6 Finance Report for Month 7 10:35 Review and discuss the finance report Sponsor: Ian Howard, Chief Financial Officer 5.7 People Report for Month 7 10:45 Review and discuss the people report Sponsor: Steve Harris, Chief People Officer 6 Break 10:55 7 Infection Prevention and Control 2022-23 Q2 Report 11:05 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Interim Lead Infection Control Director/Julie Brooks, Head of Infection Prevention Unit 8 Medicines Management Annual Report 2021-22 11:15 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist 9 Equality, Diversity and Inclusivity (EDI) Update including Workforce Race 11:25 Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) Results 2022 Receive and discuss the reports Sponsor: Steve Harris, Chief People Officer Attendee: Ceri Connor, Director of OD and Inclusion 10 Annual Ward Staffing Nursing Establishment Review 11:35 Discuss and approve the review Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Rosemary Chable, Head of Nursing for Education, Practice and Staffing 11 Guardian of Safe Working Hours Quarterly Report 11:45 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 12 Learning from Deaths 2022/23 Quarter 2 Report 11:55 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Ellis Banfield, Associate Director of Patient Experience 13 Freedom to Speak Up Report 12:05 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian Page 2 14 Annual Assurance Process and Self-assessment against the NHS 12:15 England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Joe Teape, Chief Operating Officer Attendee: John Mcgonigle, Emergency Planning & Resilience Manager 15 STRATEGY and BUSINESS PLANNING 15.1 Board Assurance Framework (BAF) Update 12:25 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 16 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 16.1 Register of Seals and Chair's Actions Report 12:35 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 16.2 Review of Standing Financial Instructions 2022-23 12:40 Review and approve the SFIs Sponsor: Ian Howard, Chief Financial Officer Attendee: Phil Bunting, Director of Operational Finance 16.3 Corporate Governance Update 12:50 Receive and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 17 Any other business 13:00 Raise any relevant or urgent matters that are not on the agenda 18 Note the date of the next meeting: 31 January 2023 19 Items circulated to the Board for reading 19.1 CRN: Wessex 2022-23 Q2 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer Page 3 20 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. 21 Follow-up discussion with governors 13:05 Page 4 3 Minutes of Previous Meeting held on 29 September 2022 1 Draft Minutes TB 29 Sept 22 OS v2 Minutes Trust Board – Open Session Date Time Location Chair Present 29/09/2022 9:00 – 13:00 Microsoft Teams Jenni Douglas-Todd (JD-T) Jane Bailey (JB), Non-Executive Director (NED) Gail Byrne (GB), Chief Nursing Officer Cyrus Cooper (CC), NED (from item 5.4 part two) Jenni Douglas-Todd (JD-T), Chair Keith Evans (KE), NED David French (DAF), Chief Executive Officer Paul Grundy (PG), Chief Medical Officer Steve Harris (SH), Chief People Officer Jane Harwood (JH), NED Ian Howard (IH), Chief Financial Officer Tim Peachey (TP), NED Joe Teape (JT), Chief Operating Officer In attendance Jane Fisher, Head of Health and Safety Services (JF) (for item 7.3) Sarah Herbert, Deputy Chief Nursing Officer (SHe) (for item 5.7) Femi Macaulay (FM), Associate NED Corinne Miller, Named Nurse for Safeguarding Adults (CM) (for item 5.8) Karen McGarthy, Named Nurse for Safeguarding Children (KMcG) (for item 5.8) Christine McGrath (CMcG), Director of Strategy and Partnerships Helen Potton, Associate Director of Corporate Affairs and Company Secretary (Interim) (HP) Helen Ralph, Manager, Transformation Team (HR) (for item 6.1) Annabel Shawcroft, Clinical Programme Officer, Transformation Team (AS) (for item 6.1) Jason Teoh, Director of Data and Analytics (JTe) (for item 5.11) Diana Ward, Clinical Outcomes Manager (DW) (for item 5.10) One member of the public (observing) 3 governors (observing) 5 members of staff (observing) 1 members of the public (observing) Apologies Dave Bennett (DB), NED 1. Chair’s Welcome, Apologies and Declarations of Interest JD-T welcomed all those attending the meeting which was being held by Microsoft Teams. Apologies were received from DB. CC would be joining the meeting later. 2. Patient Story HP introduced the Patient Story which focused on the experience of a mother and daughter who had used the Trust’s services. Mum advised that during the pandemic, her daughter had been diagnosed with cancer in her abdomen at the age of nine years old. Page 1 Her daughter had surgery followed by nine rounds of chemotherapy at the Trust followed by radiotherapy in London. Whilst on maintenance chemotherapy her daughter had relapsed and sadly a decision was made that further treatment would not be beneficial. Her daughter’s response was to write a “bucket list”. Some of the items were for herself but some related to changes that she wanted for other people including wanting parents to be fed. Her daughter could not understand why, when she was asked what she wanted to eat, that this did not extend to her mum, when her mum was in the hospital supporting her. Her daughter had not wanted mum to leave to go and eat, and no one else could come to sit with her because of the COVID restrictions. Her daughter was scared and going through gruelling treatment and that made it very difficult for mum to leave her. In addition, her treatment had affected her smell, making her feel unwell which resulted in her mum eating in the ensuite toilet as there was nowhere else to sit and eat. After her daughter died, mum had been working on items from her daughter’s bucket list, with senior representatives of the NHS. Work focused on putting in place a national programme to feed parents, improve food for children and also the provision of play specialists. In terms of food, mum had been working with UHS’ Patient Support Hub since January. Initially snack and toiletry boxes were put into every parent room but now, every children’s ward across Portsmouth and Southampton, a total of 17 wards, received food and drink every week. A charity, Sophie’s Legacy, had been set up and a trial had started that provided parents with a £4 food voucher for the restaurant, which was in addition to the support provided by the Patient Support Hub. The initiative had been well received by parents. The hope is to roll this out across the Country as looking after parents was important to enable them to support the care of their children. JD-T thanked mum for sharing noting how devastating it must have been to lose her daughter and how amazing it was that she and her daughter had wanted to support others in this difficult time. GB also thanked mum for sharing the experience and the work that was being done in her daughter’s name, which was important to continue. DAF noted how extraordinary that at the age of nine her daughter was considering the future of others. DAF asked whether mum had good links with the hospital charity and SH confirmed that he would make contact to ensure that this happened. Action: SH JT noted the importance of good facilities being available including good quality, affordable food. It was important for the Board to look at this and also to look at the estate to ensure that there was appropriate spaces provided for parents. 3. Minutes of the Previous Meeting held on 28 July 2022 The minutes of the meeting held on 28 July 2022 were approved as an accurate record of the meeting save for the following amendments: Page 2 • Page 3 – Correct spelling of Beachcroft • Page 3 – 5.3 third bullet – should read compliant not complaint. 4. Maters Arising and Summary of Agreed Actions Actions that were due had been completed. Action 763 – The complaint data was being compiled and would be sent out shortly. The remaining actions were not yet due but were being taken forward. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee KE provided a briefing following the meeting on 12 September. The External Auditors had signed off their opinion on the financial statements with a clean opinion being given. From the Internal Auditors three reviews had been completed. The incident management review had focused on smaller incidents, noting that major incidents would normally be highlighted quickly. A large number had been tested and the conclusion was that the Trust needed to work on turning the reports around within the ten-day period. The Cyber Security review was one of significant assurance. However, the report highlighted that the Trust did not have formal documentation in terms of a Cyber Security Strategy and that not much training was provided for staff. Finally, in terms of General Data Protection Regulation (GDPR) and personal information, the Trust was required to have a “record of processing activities” (ROPA). The Trust undertook hundreds of activities but did not have a ROPA for every activity and the recommendation was to review and put in place an appropriate policy to enable a more general approach for wider coverage. The final review was stage 2 of how the Trust managed and governed IT projects. The report had focused on three areas: • The initial assessment of the benefits of the IT project which had been found to be thorough and well thought out and documented. • More guidance was recommended on how to evaluate benefits particularly in terms of non financial benefits including safety benefits. • There were very few post benefit assessments being completed which would help with learning. Plans were in place to put additional controls in place by March 2023 and a review would take place as part of their follow up procedures. JT reminded members that he had arranged for Cyber training for the Board and had agreed to provide further assurance around some of the arrangements and the Internal Audit was aligned to this. JT noted that staffing arrangements would need to be reviewed as currently there was only one colleague within the digital team that worked on cyber security issues. HP informed the Board that work was already underway in terms of the work around ROPAs. Action: JT Page 3 5.2 Briefing from the Chair of the Finance and Investment Committee JB provided an update from the last meeting noting that discussions had taken place around the current financial position and the operational plan, both of which were due to be discussed in the closed board meeting. There was significant challenge particularly around the deficit position but overall there was a really good grip on exactly where the Trust currently was, with appropriate decisions being made to reflect the balance between managing the financial position, whilst continuing to support our people and activity. A number of ongoing actions around productivity were being addressed together with a clearer view of the future cash position of the Trust. Finally, JB noted that Model Hospital data had been reviewed to enable the Trust to drive efficiencies compared to other hospitals and to facilitate learning. 5.3 Chief Executive Officer’s Report DAF noted that this was the first time that the Board had met since the death of Her Majesty Queen Elisabeth II and wanted to formally recognise the fantastic public service that she had given. The state funeral, which gave an additional bank holiday, provided the Trust with some challenging operational issues, with little guidance being provided in terms of what the best approach should be. Where staff were not involved in urgent or emergency care, such as within outpatients, electives and day case procedures, they were given the choice that if they wanted to work that would be gratefully received, but similarly if they wanted to take the day off to pay their respects, they were able to. Some staff wanted to work and others wanted to take the day. More than two thirds of the scheduled activity had been undertaken. DAF thanked all staff for all of their hard work and dedication. He also noted that: • The pilot of the care village had been very successful and would be discussed further in the next item. • Junior doctor pay rates had been quite challenging and was symptomatic of where the Trust was with many members of the workforce. The Royal College of Nursing (RCN) had notified the Trust of an intended ballot for strike action. Also, the British Medical Association (BMA) had published a rate card that they wanted trusts to pay, which was in many cases, significantly above current ratees. DAF noted that there were groups of staff who had indicated that they would not work for the Trust unless paid the new rates. It was a period of instability and people were understandably wanting to protect their income which was manifesting in the behaviours that we were seeing. • The HR team had been recognised by the Chartered Institute of Professional Management (CIPD), for a National awards which was a testament to the good work that SH and his team did. • The number of COVID positive cases was increasing with around 70 currently in the hospital. Mask wearing had been re-introduced in clinical areas in an attempt to limit the number of nosocomial transmissions. Care homes were not willing to accept patients with COVID which would impact potential discharges. In terms of staff Page 4 absence from COVID this was also increasing and staff were being encouraged to have both COVID and influenza vaccinations. • UHS was in the process of finalising an IT contract which, at first glance looked like it could be a replacement for our Emergency Department (ED) IT system. The initial contract was small but included from a strategic perspective, as the Trust had recognised the potential for having a longer-term development partner. UHS remained committed to its “Best of Breed” strategy but had been struggling to recruit and retain the people needed to develop the systems and this could be a step to delivering this by working together in partnership. Ultimately this could result in UHS not only being able to bring to develop our systems but also had the potential to bring to the market a number of our IT products that we had developed. • At the previous month’s board, the Trust had been aware of its segmentation under the Single Oversight Framework (SOF) review, but had omitted to formally advise the board. The Trust remained in segment 2, with 1 being good and 4 being bad. Trusts in segments 3 and 4 received more dedicated support and oversight. This was a vote of confidence from the regulators in the Trust despite the challenges it was facing. TP noted that the BMA pay card had received much criticism and should be resisted unless there was a proper negotiation about the rates. In terms of the IT partnership this was excellent news. PG noted that the Trust had been very clear through the Local Medical Councils (LMC), and individual conversations with teams, that the Trust would not be entering into negotiations about the BMA rates. It was growing as an issue but was an untenable position to hold in front of the rest of the workforce. Meetings were taking place with teams noting that it was not just about money. PG had been clear with his medical consultant colleagues that he was not able to recommend that consultants were paid as much in one day for an overtime operating list, which was greater than the amount some staff received in a month. In a cost-of-living crisis this was wrong. Many colleagues had understood this approach but there was still many who were very unhappy. JH congratulated SH for the award noting that this was a very difficult award to achieve, with tough competition, and that to achieve it during the pandemic was outstanding. Decision: The Board noted the report. 5.4 Integrated Performance Report for Month 5 (part one) JT noted the challenges that the Trust was currently under and in particular highlighted: • The previous day had been particularly tough with every space in the hospital full and lots of patients in the ED waiting for beds. This was replicated nationally with many organisations had declared critical incidents due to the pressures being faced. It was caused by increased numbers of COVID positive patients and a big spike in the number of delayed patients in the hospital which had hit 245 patients at the start of the week, with almost a quarter of the bed base who could be treated elsewhere. Page 5 • There was a record number of cancer referrals with the waiting list being the highest it had ever been. The Trust continued to deliver more diagnostic capacity than it had ever delivered but continued to struggle with capacity in view of the increased demand. This was a very difficult position alongside a time where staff morale was low and staff were tired due to the pressures over the last couple of years. • One of the two spotlights related to cancer and the Board had a study session the following week with a deep dive. Referrals had grown by about 25% per month from around 1600 two-week referrals to consistently above 2000 per month. The backlog of patients who had breached 62 days had gone up three-fold in the last two years from around 100 to 370 patients. The overall number of patients on the cancer pathway had also doubled in this period. This was challenging for a group of patients that the Trust wanted to prioritise in terms of access to services and care. • Across the Wessex Alliance footprint the backlog remained better than the rest of the Country but it was not where we would want to be in terms of cancer services. It was likely that our performance would dip as we started to treat those patients which would impact the 62 day target, despite the levels of activity and delivering relatively well in terms of our peer groups. • There were some excellent new pathways being developed including the dermatology dream pathway which would make a significant impact on the skin pathway once implemented. Work was also being done with the cancer allowance to map what we had, against what we needed to understand better the gaps. DAF noted that the cancer performance metrics were a measure of the patients that had been treated. Once you had a number of patients above the 62 days, if you did not treat them and let them remain on the waiting list. your measure would remain strong. However, this was not the right thing to do but once you had treated them this would impact that metric which was likely to be poor over the coming months. TP noted that the waiting had continued to get bigger which would suggest that either the Trust was not coping with the numbers coming through and people were therefore waiting longer and longer or that there was a higher rate of cancer in the population. Was this as a result of COVID reducing the body’s ability to fight small cancers that would normally disappear. JD-T also noted the highest number of referrals happening in August and wondered whether there was any national modelling being done around this. JT informed members that Professor Peter Johnson would be one of the presenters at the board study session and this would be a good opportunity to explore this. Anecdotally we appeared to be seeing more sicker patients who had a number of co-morbidities presenting as more complex patients and work was underway to investigate this further particularly from an inequality lens in terms of the demographics that were being referred on the two week wait referrals. PG noted that during COVID people tended to not present which was part of the reason for a backlog of presentations but that diagnosis appeared to also be increasing. Understanding why was not yet known and a discussion in the study session would be helpful to understand that particularly better. In terms of the appraisals spotlight SH noted: Page 6 • That a key element from the People Strategy was the Trust’s ability to provide meaningful progression for our staff. From the feedback given in the staff survey many staff believed that during the pandemic they had not received the development, training or the appraisal focus that they would have wanted. • Work to address that included a multi disciplinary team who had focused on refreshing the appraisal paperwork which had been well received. The team had a wide breadth of staff including clinical, operational and trade union representatives. Previously the number of appraisals carried out had been good but the quality had been low so training for appraisals had been reviewed to improve the quality of the appraisal discussion. Whilst the Trust was better than its peers, this simply highlighted that the NHS was not particularly good at appraisals. • A pilot had been implemented to better align appraisals with objective setting to enable them to cascade down to staff better which would conclude shortly and would feed into the process. JD-T noted that Division D consistently outperformed the other Divisions in terms of completed appraisals. In addition the staff survey showed that they were the only division that achieved a green in terms of an appraisal helping staff to undertake their job. This showed a correlation between the two and wondered what was the learning was. SH noted that Division D had historically had good rates of completion and had been involved in the refresh and had highlighted the need to focus at every level of the team. JH asked whether those within Division D had better promotion and development opportunities which could link back into the value of conducting a good appraisal. SH advised that there was nothing obvious but Division D had some good engagement scores overall but this could be looked at further. GB noted that the new appraisal paperwork had removed the need to consider how an individual contributed to the values of the organisation, and although the values were still referenced, questioned how through appraisal the behaviours and values continued to sit within the process. SH noted that the review of the values work was important and it would be good to look at how that could be brought back into the appraisal process to add value. Decision: The Board noted the report. 5.5 Finance Report for Month 5 IH presented the report and highlighted: • The Trust continued to focus on the underlying deficit, which for months 1 – 4 had been around £3m which had slightly worsened to £3,5m as energy costs started to grow. A deep dive had taken place at the Finance & Investment (F&I) Committee looking at some of the actions being undertaken and some of the future forecasts before the energy cap would come in and whether this would help or otherwise. There would still be a small increase in run rate into the latter half of the year which would deteriorate the Trust’s underlying position as we entered the winter months. • The key drivers were consistent. As well as energy prices, there were some drug costs pressures as we were on a block contract, cost associated with COVID including backfill of staff together with all of the operational pressures that had already been discussed. Page 7 • Cost Improvement Programme (CIP) performance had improved following the introduction of the Cost Savings Group. The Trust was currently achieving more than 80% identified which should increase going forward. In month delivery had also been strong. Everything was being done to try and improve the financial position but there were a number of pressures that were outside our control that would impact this. • Elective recovery framework performance had dipped in line with the operational pressures discussed, but UHS continued to achieve 106%, above the required 104%. UHS was in the top Trusts both in the region and nationally in terms of activity levels compared to 2019/20 levels. However, this was not resolving the waiting list issue that continued to grow. UHS continued to do well in terms of 2019/20 levels compared to other Trusts but this did create a financial pressure. • The Trust had reported a £12m deficit. The Hampshire and Isle of Wight deficit was £53m. This was an outlier within the region, and the region was an outlier nationally. This had resulted in the system becoming an outlier in terms of financial performance which might have adverse consequences going forward including upon the SOF rating. • The underlying deficit reduced the Trust’s cash balance and that may put pressure on our future capital investment programme. KE referred to the financial risks table and asked what the difference was between the original worst case of £57m and the forecast assessments which showed, best, intermediate and worst case? IH noted that the original worstcase scenario had been presented to the Board as part of the planning submissions, to show the range of possible financial outcomes with everything that was known at the time. The current best, intermediate and worst case were the current assessments. KE noted that UHS could not control COVID costs, energy costs and inflationary measures and that this would need Treasury to provide support. IH reminded members that nationally there was a drive to find efficiencies. It was likely that many Trusts would go into deficit this year but it was not clear what the response would be to that. KE commended the work on the CIP which was a fantastic achievement. He questioned whether the position could improve further with more CIP savings. IH advised that a target date of Month 6 had been agreed in terms of everything being identified 100% and the position might improve next month. IH noted that UHS was at 106% activity levels with the national average being around 94%. The 12% from the Elective Recovery Fund (ERF) would be worth about £20m to the Trust. If the Trust had undertaken less activity the Trust’s financial position would be a lot less stark but UHS continued to put patients first and try and balance performance, money and quality. In response to a question from JD-T IH confirmed that as of today and what was currently known, UHS could still achieve the best-case scenario. DAF suggested that in view of what had happened in markets over the recent days it was unlikely that the NHS would want to approach the Treasury. UHS should proceed on the basis that there would be no financial support being provided. In those circumstances the Board would need to consider at what point more significant interventions would need to be made. Page 8 5.6 People Report for Month 5 JD-T noted that this was a new report for the board. Previously the report had been presented to the Trust Executive Committee (TEC) and following discussion in that forum a decision was made that it should be presented to the open board for discussion. SH presented the report and noted that the version before the Board was the detailed report presented to TEC. Going forward a more streamlined report, with key highlights, would be developed for the Board discussion. SH highlighted: • Some of the key actions that had been taken in relation to recruitment and retention and also the cost-of-living crisis. There had been discussions at a previous closed board meeting around concerns in relation to the recruitment and retention of certain staff groups and some actions had been put in place to mitigate those concerns. • SH highlighted the challenges around Advanced Clinical Practitioners (ACPs) and pay rates. A few local organisations including GP practices were providing a differential rate of pay with a higher pay band. In the short term this was being addressed by a recruitment and retention premium to bridge the gap, together with conducting a workforce review that would seek to understand the banding and whether there was a need for a permanent band change. However, it would be important to consider the possible impact on the change to other bands across the Trust and manage that appropriately. • UHS continued to undertake Health Care Assistant (HCA) recruitment well, but the challenge was retention. There were good pathways in place but work was needed to strengthen landing boards and increase the support available in the hubs and implement some band 2 to band 3 progression roles for those who did not want to utilise the nursing apprenticeship route. • Demand on the recruitment team had significantly increased with a 25% increase of requested support. Some additional resource had been agreed to support them both within the organisation but also to increase engagement outside of the organisation. • In terms of cost of living, SH had been undertaking a lot of work with partners across the Trust including trade unions and listening to staff voices. There were a number of elements that were not under the Trust’s control including the national pay award and the rising energy crisis so the approach being taking was to take a balanced and fair approach. A number of things would be implemented which would be highlighted to all staff. A substantial discount was being negotiated in the restaurant to help people to eat a broad range of foods at competitive prices. The cycle to work scheme was being expanded, and there was some targeted support for those with high mileage within the organisation. For the 200 or so families who used the nursery the price was being rolled back to April this year. • The Trust already has a range of general support which would be expanded to make sure that we were targeting the right people. Through a partnership with the ICS we were linking up with the Citizens Advice Bureau to provide really high quality financial advice to our staff. We were focusing on crisis, and working with the Charity, had set up a hardship fund of £20,000 which would be distributed to the most challenging cases where staff had been identified as a particular Page 9 hardship case they would be able to eat free at the restaurant. Arrangements had also been made with a local charity to provide vouchers and food parcels. Discussion had taken place as to whether a food bank should be set up on site which logistically would have been difficult, so the decision to work with the charity was agreed to be the best approach to deliver that service for us. • Discussions had taken place at the Trust Executive Committee (TEC) who had fully supported the measures noting the impact on the nonrecurrent spend. KE suggested that this was a very sensible, targeted group of things to support our people. However, asked if the cost of £2.3m was currently included in the financial reports. IH advised that it was not included although some of the nonrecurrent elements had a funding source so would not hit the underlying position. In terms of annual leave buy out there were accruals from previous years. However, there were some recurrent costs. The measures were targeted, proportionate and in line with the Trust’s values for the current pressures being faced and if the Trust did not do anything it would likely increase costs or consequences elsewhere. DAF noted that the report was the same as presented to the TEC at which there had been a more detailed conversation. It would be helpful to understand which areas of the report were more relevant and appropriate for the Board conversation which could be discussed at the next People and OD POD) Committee meeting. Action: SH. JH supported the proposals within the paper and noted that they had also been presented to the People and OD Committee (POD). POD would be tracking the progress of each of the initiatives to ensure that they were delivering as anticipated. JH asked if the Trust had looked at what others were doing to ensure that we were doing everything possible for our staff. SH confirmed that discussions had taken place locally and that the Trust was one of the first to implement the range of measures which were similar to those of others. Nationally, there had been a push to have a collective response, noting that the NHS employed 1.5m people and that there would be national support that would be available shortly. TP noted the importance of having a people report at the Board and whilst the contents were good suggested that they could be presented in a more accessible way. FM also noted the importance of the report and discussion but wondered what staff morale was. If the finance, performance and people report were considered as a whole it was clear that staff were facing a lot of pressure and there was insufficient staff due to high turnover. The volume of patients was increasing which meant that the staff that the Trust did have, had to work harder and longer with pay that was not great and a cost-of-living crisis to deal with. This must have an impact on staff morale and was there also an impact on patient care? SH noted that morale was challenged which was recognised in the executive updates. The Trust undertook a quarterly staff survey alongside the current national annual staff survey and those results have been included within the report. The recent results discussed motivation, engagement and advocacy in Page 10 the organisation and UHS scores were still consistently in the top 10 of the NHS. However, the entirety of that engagement score was deteriorating. Morale was challenged and how that impacted on care was discussed in other forums. GB chaired the Quality Governance Steering Group (QGSG) which fed into the Quality Committee and focused on quality whether that be from the engagement of our staff or other challenges. GB suggested that it was a mixed picture. People enjoyed working as a team and we can see them pull together and work as a team through the challenges. There were a number of different pockets in the organisation who believed that they were in a worst situation following the pandemic and it was important to move out of that space and recognise this as a whole. In terms of quality, it was important to retain a close focus on quality and in some other Trusts they were starting to experience a significant challenge with regards to their quality indicators. At UHS there were some potential early indications that were being closely monitored. Without a doubt staffing levels, and the way in which we looked at the wards, impacted on patient experience and outcome. JD-T noted that one of the proposals was for staff to be able to sell back annual leave and being able to easily access the bank but if this was considered in the wider context, we had staff who were tired and not able to take leave as they had sold it, and were looking to work extra hours on the bank. How did the Trust manage and balance this? How should we look at the overarching risks for the workforce, and consequently patient care and performance, and what were the things that we needed to do to balance that. It would be helpful if the report could address some of those challenges to help the Board’s understanding. In addition JD-T asked NEDs to feedback what they would want to see within the report to enable an effective discussion. Action: SH and All NEDs JH asked about exit surveys and wondered if there was any information from them that could support our approach. SH advised that approximately 30% of staff completed exit surveys which needed to be increased. Pay for the lower paid staff had become an issue. SH reminded members that he chaired the ICS people officers group and that group had been looking at how collectively they could support retention and were looking to purchase better exit surveys for the system pulling together their collective buying power. Decision: The Board noted the report. 5.4 Integrated Performance Report for Month 5 (part two) Having noted the previous discussions under items 5.5 and 5.6 JD-T suggested that a discussion on the remaining of the IPR would be helpful and the following questions and comments were made: • JB noted that on pages 31 and 35, F1 – F5 this suggested that in terms of digital we believed that this was going to transform our efficiencies but it was not clear what the metrics indicated nor were some of them very high. PG suggested that there was an amazing resource in my medical record which we were not really making the most of. Work was needed to raise awareness with both patients and clinicians. Having used it as a patient it had been really helpful and enabled him to go paperless. JT noted that there was a business case that was overdue Page 11 for my medical record around how we industrialised it across the Trust which should provide some huge benefits and would bring a timeline back as to when this would happen. Action: JT JT noted that there was some big digital change happening with the rolling out of speech recognition and some E tools. In addition it would be helpful to look at the indicators to understand whether they were the right ones and review them as part of the digital updates which could be discussed at F&I. Action: JT The Board discussed the importance of giving people an overwhelming reason to access my medical record noting that the NHS App had initially been used for COVID vaccinations but could now enable people to order prescriptions and book appointments. JD-T noted the Serious Incident reports and the number of harm falls which looked higher than previously and wondered in terms of the pressures we were seeing and the issues around workforce should the Board be concerned about this? GB advised that it had recently been falls awareness week. There had been a number of successful programmes in the Trust including bay watch, but with reduced staffing numbers that had became a challenge and some more deliberate high impact actions were needed to reduce those falls. A deep dive into this would be brought to a future meeting. Action: GB GB confirmed that COVID numbers were rising. There were 66 patients with COVID some of whom were both asymptomatic and symptomatic. 5.7 Break The break took place prior to the Safeguarding Annual Report. 5.8 Safeguarding Annual Report 2021-22 and Strategy 2022-25 JDT suggested that the strategy should be discussed first noting that both had been discussed at the Quality Committee. KMcG presented the strategy which had previously been presented to the Trust Board two years ago before Covid. The strategy had been reviewed and updated in line with new legislation and aligned to UHS values and now included maternity services. Some of the strategy linked to children and adult reviews and making safeguarding personal together with our partners and developing stronger links within maternity, the emergency department and the wider hospital. Joining this up with the domestic abuse strategy and ensuring that we were always improving particularly around training and education including level 3 requirements. In terms of the Annual Report from a children’s perspective there were three main highlights: Page 12 • A significant increase, from 3700 to 6004, in the number of information sharing forms (ICF) which come through the ED where a child may possibly be at risk. In particular numbers had increased in the number of children presenting with mental health problems, particularly the 0 – 4 age group. This had been discussed at the Health Safeguarding Looked After Children Partnership who were looking at the 0 – 19 service provision which had changed significantly with COVID and a possible pattern of children of parents accessing through ED rather than going via their GP. • In terms of mental health, for any child who presented in the ED with a mental health condition an ICF would be completed. The number of presentations remained high. Alongside this the number of deliberate harm incidents had risen from 676 to 898, drugs and alcohol referrals had risen as had assaults over the preceding year. • Level 3 safeguarding training was at about 61%. There were two main reasons for this which was capacity and demand for the service and also a change of reporting requirements impacting just over 2000 staff. Training was on the Integrated Care Board (ICB) Risk Register as it was a wider system issue. In terms of the Annual Report for adults CM highlighted the following: • A 31% increase in safeguarding activity from the previous year with a 162% increase in Section 42 inquiries. This was due to a number of reasons including the impact of COVID including the removal of social distancing rules. • A 35% increase in the number of allegations made against people in a position of trust which was something that was being seen across other local provider organisations. These were highly sensitive cases and required significant safeguarding oversight and management alongside collaboration with HR colleagues and the relevant clinical areas, which had a significant impact on the team. • The creation of a new Mental Capacity Act (MCA), Deprivation of Liberty (DoL) and Liberty Protection Safeguards (LPS) team who supported people over the age of 16. Both locally and nationally this was one of the first teams that had been established. The team had worked to embed MCA as every day business which was key to the preparation for when LPS become law later next year or early the following year. • In terms of Learning Disability and Autism there was a lack of local provision which had been acknowledged by the ICS and work was underway in relation to service review and what this needed to look like going forward. GB thanked the team noting how hard they worked to safeguard vulnerable adults and children. GB referenced the Panorama programme that had aired the previous night in terms of a number of safeguarding issues against a Mental Health Trust. Whilst often allegations against staff were not grounded they were taken very seriously and investigated thoroughly. JB noted the 35% increase against staff and wanted to understand what the outcomes of the investigations were and whether they were justified and whether allegations were being made against different groups. CM advised that one of the key areas of allegations focused on restraint and that the level Page 13 of restraint applied was disproportionate. These would always be reviewed. Security staff worked in pairs and wore body cameras which would always be reviewed. There had not been any cases recently where that had proved to be an issue. Although there had been a big increase the total number of cases was 38 so not large numbers. The previous year there had been 23 cases. CC questioned what element of this sat within the Trust and what sat with the ICS? SH noted the importance of remembering the broader picture. Nationally there had been a rise of safeguarding incidents, but it was important to remember that our workforce formed part of that population and had struggled with lockdown and were experiencing hardship. JD-T noted the need for a system approach to manage the increased mental health demand. However, safeguarding was a key focus for the Care Quality Commission (CQC) inspections post COVID, and a local provider had recently been deemed to be inadequate due to safeguarding issues and was an issue for UHS to pay particular attention to. KMcG noted that through legislation children had the Local Area Designated Officer (LADO) which was lacking in adults, which provided a really strong link with that external partner. TP noted that there had been a detailed presentation on this in the Quality Committee. This was a national trend in increased safeguarding problems. Whatever pressure we are put under it was important not to let our safeguarding procedures slip and it needed to be protected to ensure that it worked well. Decision: The Board received the report. 5.9 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance PG presented the report which was a statement of compliance with the medical regulations and had a robust and strong process in place. PG noted that a new appraisal system had been introduced which had been well received and enabled the ability for medical staff to collect all of their appraisal information within one system instead of the previous three systems. This was beneficial for not only staff but also for those managing the process as it provided real time feedback and information both from a quality assurance perspective but also would enable better management of the process and improve appraisal rates in the future. JD-T asked whether the doctor appraisal information was included within the IPR information that the Board received and SH confirmed that it was reported separately but included in the report and currently stood at 76.7%. CC suggested that the system was good but asked whether everyone was using it. PG confirmed that the system was a mandatory one and would be the only system going forward in the future. In terms of how many staff had undertaken the process this was a little ahead of the rest of the staff. However, the system enabled us to keep better track as people would need to have completed four appraisals within the previous five years to go forward with revalidation which provided a good incentive to keep on top of this. Page 14 JD-T asked for Board members to confirm that they approved the statement of compliance. Decision: The Board noted the report and approved the statement of compliance. 5.10 Clinical Outcomes Summary PG introduced the comprehensive summary noting that the clinical lead who had ran the service for a number of years, had now left UHS and a process of recruitment was currently underway which would provide an opportunity to refresh and review. DW presented the paper and focused on the outcome programme which was unique to UHS, with 64 services out of 86 reporting their outcomes. A total of 484 outcomes had been reported all of which had been reviewed by TP via the Quality Committee. There was a thriving clinical audit programme in place. The outcomes reported per care group covered a large proportion of patients and dealt with both national and international work. In particular DW highlighted: • The Research and Development (R&D) team and the work that they had undertaken internationally on the COVID booster trial. • The Bone Marrow Transparent unit. • Maternity and the nest support teams who focused on women who may need additional support because of serious mental illness, or they were from socially challenging situations, or were non-English speaking, addiction, were homeless or were suffering from domestic abuse and other difficult situations. 12% of patients that were being seen in maternity required nest care. KE asked why 18 services were not reported and DW advised that it was because they did not have the mechanisms in place to know what their outcomes were and work was underway to support them to develop those processes. KE asked whether any of the reds within the report were really poor and JD-T noted that the data used was for 2020 and did not understand why it was so out of date. TP advised that data was provided from national audits was often two years behind, because there was a year of collection, a year of analysis and then it would be published. Within his experience he had never come across a hospital that had measured nearly 500 clinical outcomes let alone p
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Papers Trust Board - 11 November 2025

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