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Papers Trust Board - 13 January 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 13/01/2026 9:00 - 13:00 Conference Room, Heartbeat Education
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2026-Trust-documents/Papers-Trust-Board-13-January-2026.pdf

Annual ward staffing review January 2025

Description: [5.15] Report to the Trust Board of Directors, 7th January 2025 Title: Ward Staffing Nursing Establishment Review July 2024 – Octobe
Url: /Media/UHS-website-2019/Docs/About-the-Trust/performance/TB-6-monthly-staffing-review-report.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 - 7 January 2025

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

Description: OUR PEOPLE STRATEGY 2022 to 2026 CONTENTS 05 Foreword by Steve Harris – chief people officer 06 Our strategic framework 07 Always Improving 08 Insights from the UHS family 10 The National NHS People Agenda 12 Our key strategy goals 14 The collaboration between our strategic pillars 18 What are we aiming for? 22 How will we do this? 24 Time horizon 26 Measuring success 30 Governance and oversight 32 Appendix 1 – Insight work 35 “HEALTH, SAFETY AND WELLBEING, COMPASSION AND INCLUSION HAS NEVER BEEN MORE IMPORTANT. THE PANDEMIC HAS LEFT THE NHS WITH CRITICAL CHALLENGES IN EMERGENCY AND ELECTIVE DEMAND” 06 FOREWORD BY STEVE HARRIS – CHIEF PEOPLE OFFICER The Coronavirus pandemic has fundamentally shifted the way people across the world think, act and what they value. Our people at UHS have worked relentlessly through challenging conditions over this time. They are our greatest asset and, as we move into our new future, their health, safety and wellbeing, compassion and inclusion has never been more important. The days of competition for resources, for patients, and for people are over as the new world of healthcare places collaboration at its core. Working as part of the Integrated Care System (ICS) will shape and determine our future workforce planning and success. As one of England’s largest acute teaching trusts our ongoing partnership with the University of Southampton will also be a key component to recruitment and ongoing education opportunities. We will also be driven more from the central NHS approach to people leadership. With a regularly evolving national People Plan, and a new blueprint for how the Human Resources (HR) and Organisational Development (OD) profession will operate over the next 10 years. In this context the Trust developed its 5 Year Strategy – World Class People delivering World Class Care – guided by the principles of our Trust Values: Patients First, Always Improving and Working Together. One of its pillars is ‘World Class People’, our strategy for our UHS family for the next 5 years. Its success is interwoven with the wider ambitions for research and development (R&D), patient outcomes and experience, creating sustainable foundations for our future and delivering on the integrated networks agenda. A strategy for our 13,000 people in the UHS family is a big challenge. We face national and international shortages of talented people, the conditions under which our people work in are not always ideal, and people have lacked time and space to develop and grow. Our people strategy is designed to give us light, give us hope, and provide a roadmap for achieving our World Class People ambition. Steve Harris Chief People Officer 05 OUR STRATEGIC FRAMEWORK Collectively, our Vision, our Mission, our strategic themes and our Values form our strategic framework. UHS Strategy 2021-2025 World class people delivering world class care Together, we care, innovate and inspire Our vision: What we want our organisation to become by 2025; the tomorrow we are all working for Our mission: Who we are and what we do, shaping our culture and informing our objectives Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future Our strategic themes: Our key themes for the next 5 years to deliver our vision PATIENTS FIRST WORKING TOGETHER ALWAYS IMPROVING Our values: The DNA of who we are Our approach is underpinned by our systematic approach to quality improvement at every level, facilitated by the implementation of our always improving strategy. Our vision of ‘World Class People, delivering World Class Care’ is underpinned by our constant commitment to making ourselves even prouder tomorrow than we are today of the outstanding patient care, inclusive culture, spirit of teamwork and collaboration (both within and outside our organisation). That commitment is embodied in our determination to always improve which directs how we do things at UHS. We call it THE UHS WAY. The thread that brings everything together and provides a unifying measure of our progress towards achieving our corporate vision. The people strategy will deliver its part by enabling our people to thrive, excel and belong. 0137 INSIGHTS FROM THE UHS FAMILY Our people strategy is based on feedback and insights. Using a series of techniques and interventions, over 1,500 staff shared their experiences with us. This, coupled with our annual Staff Survey results, pulse surveys, and our social media insights and engagements, gave us a rich picture of what our people feel The UHS Way means to them. OD / Wellbeing initiatives Corporate strategy engagement events Staff networks and staff partnership Insight from digital channels IN SUMMARY THESE THEMES TELL US THAT OUR PEOPLE: • Want the time to ensure they can deliver their best care for our patients. • Are proud to be part of a leading teaching hospital with access to research. • Believe that inclusion and belonging is important. • Want health and wellbeing to always be a key priority. • V alue time for personal and team development and are frustrated they cannot always get this. • Were energised by the creativity and speed of decision making that was unleashed during the first wave of COVID. • Are strong advocates of UHS. • Believe that kindness, civility, and compassion are crucial. • Are concerned about the current and future pressure on UHS and the NHS. • Want better rest facilities, improved digital people systems, and a better work environment. • Want to ensure they have fair and equitable access to development and growth to be their best, whatever their background or stage in life. Insight work in Appendix 1 09 THE NATIONAL NHS PEOPLE AGENDA In 2020, The National NHS People Plan was published. This focused on 4 key areas and was underpinned by the People Promise. Together, the People Plan and People Promise are grounded in inclusion, belonging, growing and developing our people, and embracing new and innovative ways of working. In November 2021, The Future of HR and OD in the NHS was published. Following detailed consultation with stakeholders across the service and acquiring expert advice from the Chartered Institute of Personnel and Development, and Lancaster University, the reports set the blueprint for the delivery of people services in the NHS for the next 10 years. WHAT DOES THIS MEAN FOR UHS? The national direction of travel aligns well with the 5 Year Strategy for UHS. It meets our ambitions, matches the insight from our own people, and provides a platform to continue to transform people practices in our organisation. It aligns to our values, particularly a goal to ensure we are Always Improving through ‘The UHS Way’. It matches our collective ambitions to ensure inclusion, wellbeing, belonging and compassion are at the heart of our people experience. The forward plan of the NHSI People Directorate will mean, over time, our individual approach to strategy will be driven by central NHSI, and our ICS, rather than organisational goals. Our progress against national people priorities will be measured through the ICS, and NHSI regional teams. We will review and refresh our people priorities at UHS as the emergent national review begins to be implemented. The people directorate at UHS will align activities with the emerging national agenda which will include: • Enhancing our digital people offerings to improve experience and increase productivity. • Work with our partners in the ICS to build capacity and capability at scale across NHS. • D eliver the continued development of this in the people profession at UHS, ensuring we continue to recruit, retain, and grow a values-driven, agile and innovative team. • A ligning to national frameworks and policies developed as standardisation increases across the NHS. • Strengthening further our partnership with the University of Southampton (and other education partners) to deliver our shared ambitions in education, workforce development and enhanced career opportunities. 11 OUR KEY STRATEGY GOALS To achieve our ambition of World Class People our strategy sets out 3 key areas of focus. These will inform our intention to grow our UHS family to: 1. T HRIVE by looking to the future to plan, attract and retain great people and to ensure every area is resourced to meet demand. Working with our education partners, we will invest in opportunities for people to nurture and grow their skills, as well as work with them to grow our future workforce. We will offer flexible careers and make the best use of technology to ensure we plan and deploy our people to provide safe, high quality care. 2. E XCEL within an organisation where forward-thinking people practices are delivered at the right time and where team structures, culture and environment are all designed to support wellbeing and develop potential. We will deliver progressive opportunities for individuals to develop their knowledge and skills to become their best selves. We will recognise and reward our people for the great work they do in well-designed roles that provide the freedom to innovate and improve. 3. B ELONG in a compassionate, inclusive and welcoming environment that values and supports every individual, both personally and professionally. We will ensure that every person feels free and comfortable to bring their whole selves to work, safe in the knowledge that they are welcomed, respected and represented. These 3 principles will guide our activities, allocation of resources, and the management of our capacity and capabilities. 15 THE COLLABORATION BETWEEN OUR STRATEGIC PILLARS World Class People is critical to the delivery of the four other strategic pillars in our 5 Year Strategy. Our people, and the innovation, quality, motivation, and care they provide, is critical to driving our strategy forward. The co-dependency and collaboration between pillars is critical to success. • Recruiting, retaining, and developing compassionate, inclusive people. • F air and Just culture – learning from sucesses and improving from errors. • Caring for our people so that they can care for others. • H arnessing the power of our diversity to improve our patient experience. • A ttracting and retaining the best clinical minds to UHS. • Supporting time and space for innovation in all our professions. • Strong partnership with the University of Southampton in the people space. • People agility and flexibility across organisational boundaries. • Seamless movement between Trusts. • B uilding people capacity at scale in the ICS. • S tandardisation of roles, terms, policies across the ICS. • A deeper partnership between the NHS, social care, and third sector to meet people challenges. • Sustainable, fair, flexible employment to grow opportunity. • Building social purpose. • Growing our future workforce. • Improving health and wealth through great employment. • Productivity and value for money through people practices. • A chieving net zero through the engagement, energy, and passion of our people. • P roviding and maintaining a fit-for-purpose estate and environment for our people. 17 “THE WORLD CLASS PEOPLE STRATEGY IS ABOUT GROWING AND DEPLOYING THE WORKFORCE OF TODAY AND THE FUTURE. A THRIVING COMMUNITY, DELIVERING WORLD CLASS PATIENT CARE AND PEOPLE SERVICES” WHAT ARE WE AIMING FOR? AREA OUR GOALS Meeting demands through innovation, focus on people, and development of talent: • P LAN AND INOVATE – Design a workforce plan which aligns to the ambitions in our Digital Strategy and Always Improving Strategy, where we develop roles for the future, aligned to transformation and emerging clinical practice. As key collaborators with our ICS partners we will focus on workforce capacity, growth and sustainability now and in the future at scale. • EDUCATE – Work with the University of Southampton, our wider education partners, and ICS colleagues to grow our future professionally qualified workforce capacity, specifically through more qualified nurses, Allied Healthcare Professionals, scientific and technical roles, and junior doctors. • ATTRACT – Develop a comprehensive inclusive talent attraction plan which will: • Expand our overseas recruitment. • Increase our apprenticeships with an ambition to grow our own. • Offer career pathways and progression routes. • Ensure succession plans for all leadership roles and critical/hard to recruit roles. • Work with people in local communities to attract future talent into UHS and the wider NHS.➢ • E nsure a diverse and representative UHS leadership and workforce community. • Focus on a flexible employment offering to meet diverse needs. • Maximise our opportunities as a university teaching hospital. • INSIGHT – We will develop our people analytics, creating insights and intelligent dashboards to enhance the rigour of decision making. • L EARNING – Transforming professional learning and development to a more inclusive, discovery-based approach, self-driven development of knowledge, skills and experience, supported by leading educational provision. • AGILE DEPLOYMENT – Agile deployment; maximising technology and workforce systems to ensure skills and experience are in the right place at the right time. Greater flexibility to work at UHS and through our partner organisations in the ICS seamlessly. • CONTINGENT WORKFORCE – Ensure maximum value and opportunity from our contingent workforce focusing on agency, bank and our volunteers. AREA OUR GOALS • HEALTH AND WELLBEING – The health and wellbeing of our people is a top priority. We will ensure we consider the impact of wellbeing initiatives and activity to promote and sustain wellbeing and a healthy work environment. We will focus on what really makes a difference in supporting people to stay well and healthy, and strive to achieve these. • T HE UHS CAREER PROMISE – Everyone has a career plan who wants it. We will refresh our appraisal and performance system to ensure continual feedback, and clarity of purpose for all roles, connecting people to The UHS Way. We will link our careers opportunities and support to diversity, including different parts of peoples life experience and expectations. • LISTEN AND ACT – We will listen to our diverse UHS family, integrated team members, partners and communities to develop a deep understanding of how they are treated and what it feels like to work at UHS, and to respond accordingly. We will seek to make year-on-year improvements in the annual NHS Staff Survey and continue to raise participation. • REWARD AND CELEBRATE – We will reward people for the amazing work they do. We will celebrate success and raise the profile of our people and teams regionally and nationally. We will ensure our reward and celebration reflect our amazing diversity with the UHS family. • A WHOLE EMPLOYMENT APPROACH – We will major on the “UHS experience”, we will delight people from our advert, to our induction, and right the way through their UHS journey. If they leave, we will ensure that is positive too. • GREAT JOBS, WELL DESIGNED – We want to get our job design right. We will simplify our processes and structures and ensure our jobs allow innovation and creativity. • N URTURING TALENT – we will grow and nurture diverse talent from all parts of the UHS family. We will enable this talent to flourish at UHS and across our partners in the ICS. • OUR EMPLOYER BRAND – We will generate a compelling offer for potential candidates through investment in our employer value proposition and brand. • OUR ENVIROMENT – We will develop our physical estate to improve the working, learning and rest environments for our people, including meeting diverse needs. • PARTNERSHIPS – We will ensure those we commercially partner with, align with our values and our expectations on the importance of the people agenda. • SAFETY – We will continue to make every effort to ensure our staff are not harmed, injured or become ill whilst at work; we will develop and implement a safety competence framework of knowledge and skills for staff in order to reduce the number of injuries and ill-health that occur as a result of our activities. • RESEARCH AND DEVELOPMENT – We will develop roles across our organisation that support our research for all strategy. 21 AREA OUR GOALS • L IVING OUR VALUES – We will aspire to live our values every day through our interactions and decision making. We will review the behaviours that underpin our values, and ensure they remain true to our strategies and the driving force behind our aspired culture. • LEADING THE UHS WAY – We will continue to invest in our leaders and managers, recognising the impact they have on our people. We will create a variety of leadership programmes, interventions and offerings which will enable leaders to develop their skills for the future and equip them to deal with current challenges. Our leaders will focus on improvement in all that they do. • B EING YOU AT WORK – We will focus on creating the conditions where people can thrive and be their best self at work, where difference is celebrated and respected. We will drive the ethos of inclusion and belonging through all our strategies, and leadership development and culture programmes. We will collaborate with external partners who will assist us in this ambition. • JUST AND LEARNING CULTURE – We will develop our culture of civility where people can confidently speak up, learn from errors and improve services. We will train more people in appreciative inquiry techniques so we can identify what works well and replicate success. • REPRESENTING ALL OUR PEOPLE – We will take positive action to develop people from underrepresented groups with an aim of diversifying leadership at all levels. • OUR NETWORKS GUIDING US – We will support our Staff Networks to grow and thrive, ensuring people can get involved, share their lived experiences, and input in to decision making. • BELONGING FOR ALL – We will tackle inequality in the workforce driven through a progressive and bold Diversity and Inclusion Strategy, and we will not tolerate bullying, harassment and discrimination towards our people. • A FAMILY OF ALLIES AT UHS – We will focus on allyship and offer bystander training for all our leaders and people. 23 HOW WILL WE DO THIS? How we approach the implementation of the people strategy is key. We will deliver our five year strategic goals through: Driven by our values Our approach to delivery will be driven by our 3 Trust values. We will keep Patients First, Working Together, and Always improving at the centre of how we work. We will listen to our people who will help us to refresh and evolve the values underpinning meaning and behaviours to meet our desired culture and strategic aims. Insight led Our approach will be driven by the insight of people, by national and local intelligence, and by industry standard practice on what works. Inside out approach Collaboration at UHS The brand of UHS will be driven by our people; our people are the core focus of our attention. Our communication will be driven by an inside out approach, where our people are the key influences and drivers of our messages, engagement, and involvement. We will aim to break down silos, work flexibly across corporate and clinical teams, and maximise talent and engagement. Our overall strategy at UHS can only be achieved by effective collaboration between all of the 5 pillars. We will proactively partner with our staffside groups, building on our strong relationships. We will continue to develop our Staff Networks to ensure diverse voice is at the heart of our decision making. Collaboration with our partners We will collaborate and share with our NHS and other health and social care partners locally and nationally to collectively address the workforce challenges of today and solutions for tomorrow. We will work to remove organisational boundaries and work together to maximise economies of scale and capitalise on innovation. Sustainability Sustainability is important to our people and it is important to the Trust. We will ensure a sustainability focused approach to our work that: • Reduces environmental impact. • Aims to deliver long term benefits for our people and our communities. • Can demonstrate our social responsibilities. Delivery through the UHS family We have so much talent and enthusiasm across the UHS family. We will deliver our goals where possible through using the creativity, passion, and experience of our people. We will develop communities of practice for OD initiatives, we will offer opportunities for people to engage on key projects and initiatives, and we will provide time, space and resources away from the workplace to do this. 25 TIME HORIZON UHS Digital Inclusion Conference Publish gender equality metrics for 2022 Refreshed our values, our talent management and leadership approach Implemented phase 1 of HR and OD overview 2021 2022 2023 UHS People strategy development Launch of our new employer brand Five year workforce and education plan Establish formal people provider relationship with ICS Completion of Banksy staff wellbeing projects Fully agile digital deployment and level 4 NHSI framework A top employer on WRES, WDES and gender metrics UHS achieving recognised industry standard award for people 2024 8% vacancy on registered nursing 2025 Expanded education 100% of apprentice levy used 2026 A top university teaching hospital in NHS staff survey 27 MEASURING SUCCESS We will measure success through clear key performance indicators (KPIs) based on best in class in the NHS and industry. These will be reported through our Trust governance mechanisms, reported to Trust Board, and through to the ICS and regional oversight groups. Our KPIS are driven by our own peoples experience (inside out), but also our comparison with peers and other industries (outside in). Our KPIs may evolve over time and may be informed by national priorities and standardisation. They will continue to be informed by the priorities at UHS, our strategy, but also the national people agenda. AREA KPI measure Vacancy rate: All staff Vacancy rate: Registered nursing All staff turnover Sickness absence NHS Staff Survey: We work flexibly NHSI levels of attainment (Rostering and deployment maturity) NHS Staff Survey: Recommendation as a place to work NHS Staff Survey: Staff engagement score Trust NHS Rank engagement of official channels on social media % of Appraisals completed NHS Staff Survey: We are always learning Source ESR ESR Current 2024 2026 Target Target 7.0% 6% 5% 13.4% 10% 8% ESR ESR Staff survey theme 13.7% 4.2% 6.4% 12% 3.4% 6.7% 11% 3.2% 7.0% National NHSI team TBA Level 1 Level 4 Annual and pulse staff survey question Annual staff survey theme Social and digital media tracking 72% 7.2% Top 5 76% 80% 7.4% 7.5% Top in all channels ESR Annual staff survey theme 72.6% 5.7% 92% 6.0% 92% 6.5% AREA All AREAS KPI measure Source Current 2024 2026 Target Target Satisfaction with quality of work environment % Apprentice levy utilised each year NHS Staff Survey: Safe environment measure NHS Staff survey: My organisation takes positive action on health and wellbeing External industry accreditation NHS Staff Survey: We are compassionate and inclusive Annual staff survey – local question from 2022 Apprentice Levy TBC Annual staff survey theme Staff survey Question 6.1% 61% Times top 100 Employers Annual staff survey theme 7.6% 60% 70% TBC TBC 6.5% 7.0% 75% 80% Award achieved 7.8% 8.0% Percentage of staff who definitely feel a sense of belonging Percentage of staff employed at Band 7 and above from non-white backgrounds Percentage of staff employed at Band 7 and above with a disability or long term condition Quarterly pulse survey ESR ESR Recommendation as a place to work from our diverse communities Quarterly pulse survey CQC Outstanding for well led CQC 74% 77% 80% 10% 14% 19% – – – Race, gender, LGBTQ+, disability and LID to mirror all staff Good Good Out- standing 29 “ENSURING CONTINUED PROGRESS AGAINST THE STRATEGY IS KEY, INCLUDING VISIBILITY TO THIS VITAL ISSUE AT TRUST BOARD LEVEL” GOVERNANCE AND OVERSIGHT Ensuring continued progress against the strategy is key, including visibility to this vital issue at Trust Board level. The strategy will become our guiding document for all activities in the People Directorate and beyond as appropriate. Each year a set of annual objectives will be set based on the five year milestones. These will be reported through our corporate objectives, through People and OD Committee and through Trust Board. Tactical decision making and governance will take place through our UHS People Board, which reports to Trust Executive Committee (TEC). Matters of inclusion will be addressed through our Equality, Diversity and Inclusion Committee also reporting to TEC. Progress will also be reported through our Always Improving Strategy Board, to ensure collaboration with other key strategic themes. A number of sub-groups will focus core activities, reporting through the UHS People Board. Collaborating with our partners The Hampshire and Isle of Wight (HIOW) People Board will provide oversight and leadership to the system agenda, and UHS will be represented through this forum, in addition to the emerging HIOW Chief People Officer collaborative. UHS People Board Trust Board People and OD Committee Trust Executive Committee HIOW collaborative: • University Hospital Southampton NHS Foundation Trust • Portsmouth Hospitals University NHS Trust • Isle of Wight NHS Trust • Southern Health NHS Foundation Trust • Solent NHS Trust Equality, Diversity and Inclusion Committee Staff Partnership Forum Pay Steering Group HR Performance Board Recruitment and Retention Group Medical Workforce Group Education Quality Group HR Policy Group ER Performance Board Staff Networks 33 APPENDIX 1 – INSIGHT WORK 35 “OUR PLAN WILL SUPPORT OUR GREATEST ASSET – OUR PEOPLE. TO BUILD A FUTURE FOR UHS WHERE WORLD CLASS PEOPLE ARE ABLE TO DELIVER THE WORLD CLASS CARE OUR PATIENTS DESERVE. WE LOOK FORWARD TO WORKING WITH YOU ALL ON THIS JOURNEY” 35 “A WORLD CLASS ORGANISATION IS MADE UP OF WORLD CLASS PEOPLE. THEY ARE OUR GREATEST ASSET” University Hospital Southampton NHS Foundation Trust Trust Management Offices, Mailpoint 18 Tremona Road, Southampton Hampshire SO16 6YD www.uhs.nhs.uk
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Plans-and-strategies/UHS-Our-People-Strategy-2022-2026.pdf

Doctor

Description: Auto Generated Title As a doctor, you can pursue a career that combines patient care with research, either as a clinical academic or through one of our other opportunities. Clinical academic career Southampton Clinical Academic Training Scheme (SoCATS) provides a career structure that aims to integrate clinical and academic training. The integrated academic career path has five principal steps: Medical school Academic foundation programme Academic clinical fellow Clinical lecturer Senior academic While intended to begin at medical school and lead to a senior academic post, there are several points at which trainees can enter and exit academic training and this hop-on, hop-off system provides considerable flexibility. Applications for doctoral or post-doctoral research training fellowships can be made to the NIHR, research councils or charities. Academic clinical fellowships and clinical lectureships are made available through open competition via a nationally developed process for academic recruitment run by NIHR Trainees Coordinating Centre (NIHR TCC) . You can find out more about the clinical academic pathway in the 2017 guide NIHR Integrated Academic Training programme for doctors and dentists . Other opportunities Clinical research fellowship These fellowships, run by Clinical Research Network Wessex , can be incorporated into your current training scheme, enabling you to contribute to research delivery and build an evidence-based clinical career. For more information, contact Dr Thomas Brown at thomas.brown@porthosp.nhs.uk . Local fellowship opportunities at UHS There are also local opportunities for research fellowships to help facilitate recruitment to clinical research within UHS. We are aware of the pivotal role of clinical fellows in supporting recruitment and expanding our portfolio of clinical research. If you are interested in these opportunities, either as a trainee doctor or as a clinical fellow with an interest in research, or you are an NHS Consultant who would like to come and talk about the potential for having a fellow to support your research, please contact our Clinical Research Physician Dr Kristin Veighey , who will be happy to meet and discuss how we can support you. Leading specific studies as a Principal Investigator (PI) You don't have to be an academic to get involved in clinical research - many of our very successful investigators have no formal research background. If you are an NHS consultant, you can combine clinical work with research, by acting as principal investigator (PI) for studies in your area of expertise. For more information on how to get started and the support that we can provide, please contact Dr Kristin Veighey or email the Research & Development (R&D) department at researchmanagement@uhs.nhs.uk .
Url: /ClinicalResearchinSouthampton/For-researchers/Education-and-training/Careerpathways/Doctor.aspx

Finance and Performance Reports 2024-25 Month 5 August 2024

Description: Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose: Finance Report 2024-25 Month 5 N/A – No meeting Ian Howard – Chief Financial Officer Philip Bunting – Director of Operational Finance David O’Sullivan – Assistant Director of Finance – Financial Performance 27 September 2024 Assurance or reassurance Approval Ratification Information X Issue to be addressed: The finance report provides a monthly summary of the key financial information for the Trust. Response to the Headlines issue: UHS reported a headline financial position of: • Month 5 - £3.8m deficit (£2.1m adverse to plan) • Year to date - £20.6m deficit (£7.6m adverse to plan) Whilst the position remains extremely challenging, there continues to be an improving month on month trend with the in-month deficit reducing from £3.9m to £3.8m. Underlying financial improvement remains more significant with month-on-month improvement being illustrated over the first five months of 2024/25. Overall Narrative The Trust is continuing to substantively deliver on financial improvements where outcomes are within its direct control. For example: • The Trust has delivered LOS improvements for P0 patients of 5%, supporting surge capacity to remain closed. • We have delivered an increase in First Outpatient appointments of 10% and Advice and Guidance of 10%, supported by a reduction in follow-up appointments of 9%. Our Outpatient First/Procedure to Follow-up ratio has improved to 53%, above the 46% national target. • The Trust has implemented new workforce controls embedded within Divisions, which have been widely supported. We are significantly below our pay expenditure plan. • We are currently utilising agency for 0.6% of our total workforce, significantly below the national target of 3.2%. • Our temporary staffing (bank and agency) is below plan by £4m, and £6m below than the same point in 23/24. • UHS is performing well on ERF activity through transformation programmes and other initiatives, with YTD performance at 126% of baselines, above the overall national target of 107% (although marginally below our plan). • UHS has delivered £25m CIP by M5, which is £4m above the trajectory from 23/24. • Since March 24, our ERF performance has increased by 9%, and at the same time our staffing levels have reduced by 2%. Page 1 of 6 However, a number of issues have presented in year which has created a financial variance, some of which are outside of the organisations full control: • Industrial Action (£1.5m) – the junior doctor strike in late June / early July has dampened the level of ERF income by c£1m and resulted in additional direct costs of c£0.5m. • Consultant pay award (£0.9m YTD) – there is a gap between funding and estimated cost of implementing the consultant pay award. • Increase to the Specialist Commissioning ERF Target (£0.5m YTD) – due to a national imbalance a further increase was applied to the ERF target for UHS that will result in unremunerated activity of £1.2m for 24/25. • System Related CIPs undelivered (£3.9m) – the four system related CIP schemes (reducing NCTR patients / reducing MH patients / Corporate cost reductions / additional service development fund income) are working collaboratively across the system; however, output metrics that support reduction in provider costs have not yet materialised. • UHS have YTD performed circa £13.5m of activity above block contract levels, which is unfunded. Further to this, within the Trust a pay underspend YTD is offsetting non pay pressures and income shortfalls against plan. Additionally, several one-off benefits have helped support the position with a VAT benefit from prior years delivering £0.7m in month. Funding Uncertainty There are a number of items expected to impact the financial position in M6 or future months. These include: • Non-recurrent deficit support funding has recently been confirmed to be received in M6. This will result in a revised financial plan from M6-M12. UHS is anticipating receiving c£11m. • ERF final performance for 2023/24 has yet to be confirmed. We are expecting a reduction to our 24/25 target, which will give an upside to our current reported position. • ERF performance to date in 2024/25 has yet to be shared – it is normally 3 months in arrears. We are estimating performance using local data. For every month that information is delayed we are increasing the level of risk and potential variation within our reported numbers. • Industrial action – we are anticipating a share of national funding, which would improve our current position. • Specialised Commissioning ERF target – as mentioned above, this was increased unexpectedly in 24/25. We have submitted a challenge nationally as part of the contractual process for 24/25 and are awaiting the outcome. • Pay award funding – we are awaiting confirmation of the value of funding to be received in relation to confirmed 24/25 pay awards, including cash to support backdated payments being made in M6. These factors could cause some volatility in reported financial positions in coming months. We will ensure our underlying position takes these movements into account. Underlying Position The Trust started the year with an underlying deficit of circa £7m per month, with underlying pressures from 23/24 being added to by real-terms funding reductions. The position has improved month on month with August estimated to have an underlying deficit of £5.5m. The year-to-date underlying deficit is evaluated to be a £30.7m deficit with £10.1m of non-recurrent benefits supporting the position hence a position of £20.6m deficit reported. Page 2 of 6 Cash The Trusts underlying deficit continues to drive a deterioration in the month-on-month cash position. August ended with a cash balance of £23.8m that is marginally higher than the recently reforecast position. As per previous updates the cash recovery plan has been enacted and close working with commissioners has helped ensure cash inflows are timely. Capital Capital expenditure of £14.2m YTD is slightly behind plan (£1.9m variance), however leaves over £44m to be spent across the remainder of 24/25. Changes to the Building Safety Act have created delays and overspends in several key projects notably the Neonatal expansion. Trust Investment Group reviewed the most likely forecast that illustrated a high degree of certainty that the capital expenditure plan for 24/25 would be delivered, however did create challenge for 25/26 with slippage greater than planned. This will be reviewed in the context of capital planning and prioritisation for 25/26 over the coming months. Pay Awards Agenda for Change pay awards and junior doctor pay awards have now been proposed for 2024/25. The resident doctors pay award has now been ratified by the BMA. As stated above the Trust has yet to receive any official guidance on the funding envelope being made available for these and how this will be distributed to providers. No funding gap is assumed within the forecast scenario referred to above. Procurement Act 2023 The Transforming Public Procurement programme introduction within the NHS has been delayed from October 24 to February 25. This will provide additional time for our procurement team (WPL) to consider all aspects of the Act, particularly as not all schedules have yet been released nationally. The Transforming Public Procurement programme aims to improve the way public procurement is regulated in order to: • create a simpler and more flexible, commercial system that better meets our country’s needs while remaining compliant with our international obligations • open up public procurement to new entrants such as small businesses and social enterprises so that they can compete for and win more public contracts • embed transparency throughout the commercial lifecycle so that the spending of taxpayers’ money can be properly scrutinised. Transforming Public Procurement - GOV.UK (www.gov.uk) https://www.gov.uk/government/collections/transforming-public-procurement WPL will provide an update to Finance & Investment Committee on the implications once a full impact assessment has been undertaken and all schedules are available. A short guide is appended in appendix 1. Next Steps • We are continuing to prioritise focus on delivery of transformation programmes, with significant energy going in across the Trust. The Trust Executive Committee in September was repurposed to focus on this. Page 3 of 6 • We are maintaining our performance on workforce through robust controls and governance. • We are engaged and supporting Tim Briggs review within HIOW, focussing on a number of specialties. • We have requested and received support from the RSP programme to bring in additional resource to support GIRFT reviews. We have identified individuals who have now started to support this programme. • Reviews of productivity movements have been progressed, including a tool which compares cost growth to cost-weighted activity movements at Care Group level. This is currently being rolled out to Divisions as a support tool to identify areas for improvement. • The Trust Savings Group process continues to provide governance and direction to a number of improvement programmes across the Trust. • We are engaging with external consultants to provide additional focused resource and deliver improvements at pace on non-pay and external contracts. Implications: • Financial implications of availability of funding to cover growth, cost pressures and new activity. • Organisational implications of remaining within statutory duties. • Trust remains within the NHSE Recovery Support Programme, until the system collectively achieves a run-rate break-even position. Risks: (Top 3) of carrying out the change / or not: • Financial risk relating to the underlying run rate and projected potential deficit if the run rate continues. • Cash risk linked to volatility above. • Inability to maximise CDEL (which cannot be carried forward) and the risk of a reducing internal CDEL allocation for 2024/25. Summary: Trust Board is asked to: Conclusion / • Note the finance position. recommendation Page 4 of 6 Appendix 1 Transforming Public Procurement The Procurement Act 2023 – a short guide for senior leaders The rules governing public procurement are changing - the new Procurement Act will improve the way procurement is done, so that every pound goes further for our public services. This transformation of public procurement represents a big change for all public bodies, which between them spend £300bn per year. It will create simpler, more flexible and effective procurement. The Procurement Act brings a range of benefits, including: • creating a simpler and more flexible commercial system that better meets our country’s needs while remaining compliant with our international obligations • opening up public procurement to new entrants such as small businesses and social enterprises so that they can compete for and win more public contracts. Further details at gov.uk/ government/publications/benefitsfor-prospective-suppliers-to-thepublic-sector • taking tougher action on underperforming suppliers and excluding suppliers who pose unacceptable risks • embedding transparency throughout the commercial lifecycle so that the spending of taxpayers’ money can be properly scrutinised We expect the new regime will go live in October 2024, following a notice period of at least 6 months. Page 5 of 6 The Cabinet Office will be rolling out a comprehensive programme of learning and development for procurement and commercial teams and other staff whose work touches on procurement need to be aware of the changes - including contract managers, finance teams, service commissioners, legal advisers and reporting teams. In order to take full advantage of the new regime, organisations should treat this as an organisational change programme. We have asked procurement and commercial teams to: • think about future pipelines of work and which procurements in 12 months+ would benefit from new flexibilities • review commercial strategies including planning, governance, assurance and resources to enable the implementation of the new regime • consider who will attend funded training and work with us on operational rollout • share the aims of reform widely with senior stakeholders and change makers • help us communicate the changes with suppliers and encourage the market to come with us There is a great opportunity to make procurement processes better to deliver outcomes for taxpayer - this needs support from budget holders and policy designers. Senior leaders can support the process by encouraging: • a named individual in their organisation to take responsibility for co-ordinating and championing the change, including within their wider organisational family where appropriate • early engagement by policy with commercial teams - this is key to delivering innovation and getting the most from the market • use of the new flexibilities in procurement and champion this change across government and wider public sector in order for this reform to be effective, we need to drive behavioural change • commercial teams to take time for the learning and development when available The Procurement Act has the potential to make a huge difference, and your engagement is essential to the outcomes we all want to see. Make sure your organisation is ready to grasp the opportunity. The Transforming Public Procurement landing page provides further information about the new regime and the L&D, guidance and support that Cabinet Office is providing. We will continue to add material here, and share resources with our network of interested parties, as we move towards go-live. See gov.uk/government/collections/ transforming-public-procurement 2024 GUIDANCE Page 6 of 6 SUPPORT Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author Date: Purpose Issue to be addressed: Performance KPI Report 2024-25 Month 5 N/A – No meeting David French, Chief Executive Officer Sam Dale, Associate Director of Data and Analytics 27 September 2024 Assurance or reassurance Y Approval Ratification Information Y The report aims to provide assurance: • Regarding the successful implementation of our strategy • That the care we provide is safe, caring, effective, responsive, and well led Response to the issue: The Performance KPI Report reflects the current operating environment and is aligned with our strategy. Implications: (Clinical, Organisational, Governance, Legal?) Risks: (Top 3) of carrying out the change / or not: Summary: Conclusion and/or recommendation This report covers a broad range of trust performance metrics. It is intended to assist the Board in assuring that the Trust meets regulatory requirements and corporate objectives. This report is provided for the purpose of assurance. Trust Board is requested to note the report. Page 1 of 17 Report to Trust Board in September 2024 Performance KPI Report Performance KPI Board Report Covering up to August 2024 Sponsor – David French, Chief Executive Officer Author – Sam Dale, Associate Director of Data and Analytics Page 2 of 17 Report to Trust Board in September 2024 Report guide Chart type Example Cumulative Column Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart Variance from Target Performance KPI Report Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). The line shows our performance, and the bar underneath represents the range of performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts is used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. Page 3 of 17 Report to Trust Board in September 2024 Performance KPI Report Introduction The Performance KPI Report is prepared for the Trust Board members each month to provide assurance: • regarding the successful implementation of our strategy; and • that the care we provide is safe, caring, effective, responsive, and well led. The content of the report includes the following: • An ‘NHS Constitution Standards’ section, summarising the standards and performance in relation to service waiting times; and • An ‘Appendix,’ with indicators presented monthly, aligned with the five themes within our strategy. • As there is no board meeting taking place for the Month 5 report, the regular ‘Spotlight’ section of this performance paper is not included for discussion. Page 4 of 17 Report to Trust Board in September 2024 Performance KPI Report Summary Areas of note in the appendix of performance metrics include: 1. The Emergency Department performance for Type 1 attendances reduced from 70.6% in July 2024 to 67.4% in August 2024. The trust ranks in 6th place for Type 1 performance when compared to peer teaching hospitals. 2. The overall RTT waiting list decreased by 1.3% from 60,461 (July 2024) to 59,649 (August 2024). This is the second month in a row that the waiting list has reduced since the peak level of 60,578 reported for June 2024. 3. The trust continues to report zero patients waiting over 104 weeks and reported nine patients waiting over 78 weeks for August 2024. We expect this number to continue to reduce to zero as corneal tissue has now been issued by the NHS Blood and Transfusion service to ensure our longest waiting ophthalmology patients are treated. 4. The trust reported 43 patients waiting over 65 weeks for August 2024 which reflects a continuous month on month reduction as we work towards the national target to have zero patients waiting over 65 weeks. Again the majority relate to corneal transplant delays. The trust ranks in first place for the latest comparative information for this metric compared to twenty equivalent teaching hospitals across the UK. 5. There was a small decline in Cancer performance for 28 day faster diagnosis (80.8%) but a significant improvement in the 31 day standard (93.4%). The Trust ranks in the second quartile when compared to peer teaching hospitals for all key cancer metrics for the latest available month (July 2024). 6. The average number of patients per day not meeting the Criteria to Reside in hospital reduced in both July (216) and August (201). 7. There were zero never events and zero Patient Safety Incident Investigations reported for August 2024. 8. The trust is reporting an increase in category 2 and category 3 pressure ulcers for August 2024. There is increased focus on educating staff on the importance of skin inspections throughout admission alongside the appropriate steps for patient repositioning throughout their spell. An update to the body map location on our Inpatient Noting system will also support that process and recording. 9. The hospital is reporting an increase in the digital metric for the number of patient logins for My Medical Record. This reflects the upload of past and future appointments for oncology patients into the system and appropriate notification to this cohort of patients. Ambulance response time performance The latest unvalidated weekly data is provided by the South Central Ambulance Service (SCAS). In the week commencing 16th September 2024, our average handover time was 16 minutes 29 seconds across 739 emergency handovers and 24 minutes 31 seconds across 45 urgent handovers. There were 47 handovers over 30 minutes and 15 handovers taking over 60 minutes within the unvalidated data. Across August the average handover time was 14 minutes 37 seconds. Page 5 of 17 Report to Trust Board in June 2024 NHS Constitution NHS Constitution - Standards for Access to services within waiting times The NHS Constitution* and the Handbook to the NHS Constitution** together set out a range of rights to which people are entitled, and pledges that the NHS is committed to achieve, including: The right to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of suitable alternative providers if this is not possible • Start your consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions • Be seen by a cancer specialist within a maximum of 2 weeks from GP referral for urgent referrals where cancer is suspected The NHS pledges to provide convenient, easy access to services within the waiting times set out in the Handbook to the NHS Constitution • All patients should receive high-quality care without any unnecessary delay • Patients can expect to be treated at the right time and according to their clinical priority. Patients with urgent conditions, such as cancer, will be able to be seen and receive treatment more quickly The handbook lists eleven of the government pledges on waiting times that are relevant to UHS services, such pledges are monitored within the organisation and by NHS commissioners and regulators. Performance against the NHS rights, and a range of the pledges, is summarised below. Further information is available within the Appendix to this report. * https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england ** https://www.gov.uk/government/publications/supplements-to-the-nhs-constitution-for-england/the-handbook-to-the-nhs-constitution-for-england Page 6 of 17 Report to Trust Board in September 2024 NHS Constitution Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug target YTD 75% % Patients on an open 18 week pathway (within 18 weeks ) 31 UHSFT Teaching hospital average (& rank of 20) 62.8% 63.2% 4 54 4 4 4 4 4 4 4 4 4 44 ≥92% South East average (& rank of 17) 5 50% 6 6 6 5 4 4 4 4 4 4 4 4 3 63.7% Cancer waiting times 62 day standard - 100% Urgent referral to first definitive treatment (Most recently externally reported data, 39 unless stated otherwise below) 67.0% 13 10 15 6 9 7 6 4 3 7 4 9 7 74.5% UHSFT 6 Teaching hospital average (& rank of 19) South East average (& rank of 17) 40% 7 3 6 1 2 3 2 2 1 3 5 3 5 6 ≥70% 39 - As of April 2024, YTD and Monthly targets changed from 85% to 70% in line with latest operational guidance 100% 63.66% Patients spending less than 4hrs in ED - (Type 1) 28 UHSFT 9 8 8 12 10 11 8 4 4 4 9 6 8 67.44% 6 10 ≥95% Teaching hospital average (& rank of 16) South East average (& rank of 16) 5 5 5 7 7 7 5 2 3 2 5 2 4 5 6 25% 40% % of Patients waiting over 6 weeks for diagnostics 37 UHSFT Teaching Hospital average (& rank of 20) 20.1% 11 10 10 8 8 7 9 7 7 7 7 6 7 7 7 5 5 5 4 5 5 5 5 5 6 4 5 5 12.8% ≤5% South East Average (& rank of 18) 0% 37 - As of April 2024, YTD and Monthly Target changed from 1% to 5% to reflect latest guidance 73.7% 68.1% 11.1% Page 7 of 17 Report to Trust Board in September 2024 Outstanding Patient Outcomes,Safety and Experience Outcomes 1 HSMR (Rolling 12 Month Figure) - UHS HSMR (Rolling 12 Month Figure) - SGH 2 HSMR - Crude Mortality Rate Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 86.72 91.18 89.58 75 3.1% 84.98 2.8% 2.5% 15% 2.6% 3 Percentage non-elective readmissions within 28 days of discharge from hospital 11.8% 12.2% 10% Monthly target ≤100 <3% - Cumulative Specialties with 4 Outcome Measures Developed (Quarterly) Q2 23-24 80 72 70 Q3 23-24 73 Q4 23-24 75 Q1 24-25 76 Q2 24-25 76 Quarterly target +1 Specialty per quarter YTD 86% 2.2% 11.9% Developed Outcomes 100% 37 41 41 36 39 RAG ratings (Quarterly) 75 67 62 77 75 5 Red 75% x Amber 333 335 334 342 327 Green 50% Red : below the national standard or 10% lower than the local target Amber : below the national standard or 5% lower than the local target Green : within the national standard or local target Appendix YTD target ≤100 <3% Page 8 of 17 Report to Trust Board in September 2024 Outstanding Patient Outcomes,Safety and Experience Safety Cumulative Clostridium difficile 6 Most recent 12 Months vs. Previous 12 Months 5 7 MRSA bacteraemia 0 80 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 90 60 35 66 47 72 55 81 65 7391 7797 84105 4 12 1219 2729 3538 4951 0 00000012120110000 Monthly target ≤5 0 8 Gram negative bacteraemia 0 19 28 16 21 15 28 20 18 22 19 16 31 25 25 29 19 1 Pressure ulcers category 2 per 1000 bed 9 days 0.44 0.53 0 1 Pressure ulcers category 3 and above 10 0.30 per 1000 bed days 0 10 0.38 0.21 11 Medication Errors (severe/moderate) 3 0 3,500 Watch & Reserve antibiotics, usage per 12 1,000 adms Most recent months vs. 2023/24 1,500 12 - Beginning June 2024, target and comparison changed in accordance with National Action Plan. 2 2,567 2,789 ≤19 <0.3 <0.3 ≤3 <2665 YTD 51 1 129 0.39 0.29 11 2,545 Appendix YTD target ≤25 0 ≤87 <0.3 <0.3 15 <2662 Page 9 of 17 Report to Trust Board in September 2024 Outstanding Patient Outcomes,Safety and Experience Appendix Safety Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Patient Safety Incident Investigations (PSIIs) 13 (based upon month reported, excluding 2 0 Maternity) 0 5 13a Never Events 0 0 5 Patient Safety Incident Investigations 14 (PSIIs)- Maternity 0 0 0.2 0.18 15 Number of falls investigated per 1000 0.10 bed days 0.0 100% % patients with a nutrition plan in place 96.7% 96.2% 16 (total checks conducted included at chart base) 788 806 798 772 770 894 879 956 930 949 889 968 976 883 868 80% 100 17 Red Flag staffing incidents 10 26 0 Maternity Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Monthly target - 0 - - ≥90% - Monthly target 480 400 501 390 517 379 633 415 448 411 409 428 429 401 483 406 392 428 469 409 446 467 442 400 424 400 382 417 450 418 Birth rate and Bookings 600 18 Birth Rate - total number of women birthed Bookings - Total number of women booked - 300 10 8 8 6 6 19 Staffing: Birth rate plus reporting / opel status - number of days (or shifts) at Opel 4. 4 3 3 4 4 1 1 0 3 0 2 - 0 100% 43.0% 44.3% 44.4% 44.8% 35.9% 53.0% 39.0% 46.5% 43.8% 46.0% 40.9% 46.7% 38.9% 50.6% 39.2% 47.3% 38.6% 49.3% 43.5% 45.2% 43.5% 44.3% 43.0% 43.5% 44.8% 44.8% 43.7% 38.6% 43.3% 43.3% Mode of delivery 20 % number of normal birthed (women) 50% % number of caesarean sections (women) - % other 0% YTD 4 2 0 0.11 95% 91 YTD - - - YTD target 0 - ≥90% - YTD target - - - Page 10 of 17 Report to Trust Board in September 2024 Outstanding Patient Outcomes,Safety and Experience Patient Experience 21 FFT Negative Score - Inpatients 22 FFT Negative Score - Maternity (postnatal ward) 23 Total UHS women booked onto a continuity of carer pathway Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 3% 1.0% 0.5% 0% 10% 2.7% 1.9% 0% 30% 15.6% 16.3% 0% Monthly target ≤5% ≤5% ≥35% 80% 24 Total BAME women booked onto a continuity of carer pathway 48.2% 19.3% 5% 100% % Patients reporting being involved in 25 decisions about care and treatment 86.0% 87.8% 80% 100% % Patients with a disability/reporting 94.0% 88.5% 26 additional needs/adjustments met (total questioned at chart base) 301 287 249 214 234 336 208 272 304 268 339 340 280 258 317 70% 26 - Performance is a scored metric with a "Yes" response scoring 1, "Yes, to some extent" receiving 0.5 score and other responses scoring 0. 200 Overnight ward moves with a reason 73 27 marked as non-clinical (excludes moves 45 from admitting wards with LOS<12hrs) 0 ≥51% ≥90% ≥90% - YTD 0.7% 2.5% 13.6% 20.9% 87.8% 88.2% 281 Appendix YTD target ≤5% ≤5% ≥35% ≥51% ≥90% ≥90% - Page 11 of 17 Report to Trust Board in September 2024 Outstanding Patient Outcomes,Safety and Experience Access Standards Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 100% 63.66% Patients spending less than 4hrs in ED - 67.44% (Type 1) 9 8 8 12 10 11 8 4 4 4 9 6 8 6 10 28 UHSFT Teaching hospital average (& rank of 20) South East average (& rank of 16) 5 5 5 7 7 7 5 2 3 2 5 2 4 5 6 25% 06:00 Average (Mean) time in Dept - non29 admitted patients 03:17 03:08 01:00 08:00 05:30 Average (Mean) time in Dept - admitted 30 05:11 patients 01:00 75% % Patients on an open 18 week pathway (within 18 weeks ) 31 UHSFT Teaching hospital average (& rank of 20) 62.8% 63.2% 4 54 4 4 4 4 4 4 4 4 4 44 South East average (& rank of 17) 5 50% 6 6 6 5 4 4 4 4 4 4 4 4 3 Monthly target ≥95% ≤04:00 ≤04:00 ≥92% Total number of patients on a 32 waiting list (18 week referral to treatment 60,000 pathway) 40,000 59,277 59,649 - Patients on an open 18 week pathway (waiting 52 weeks+ ) 8,000 4 3 3 3 2 2 2 2 3 3 4 3 2 2 33 UHSFT 1,934 1,206 ≤1393 Teaching hospital average (& rank of 20) 9 8 8 8 8 8 9 10 9 10 10 10 9 9 South East average (& rank of 17) 0 YTD 68.1% 03:12 05:27 63.7% 59,649 1206 Appendix YTD target ≥95% ≤04:00 ≤04:00 ≥92% - ≤1393 Page 12 of 17 Report to Trust Board in September 2024 Outstanding Patient Outcomes,Safety and Experience Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug target 2,000 4 4 5 5 3 Patients on an open 18 week pathway 3 3 3 3 (waiting 65 weeks+ ) 3 3 2 2 1 34 UHSFT 456 0 Teaching hospital average (& rank of 20) South East average (& rank of 17) 10 9 0 9 9 8 8 8 6 7 8 6 5 4 4 43 700 Patients on an open 18 week pathway (waiting 78 weeks+ ) 35 UHSFT Teaching hospital average (& rank of 20) 8 8 33 7 6 5 6 5 5 5 10 10 10 11 9 9 0 South East average (& rank of 17) 0 9 9 9 9 8 8 12 11 10 10 10 10 11 7 Patients on an open 18 week pathway (waiting 104 weeks+ ) 35a UHSFT 0 Teaching hospital average (& rank of 20) South East average (& rank of 17) 14 17 15 16 12 13 13 1 1 1 1 1 1 1 0 0 13 17 13 14 10 11 9 1 1 1 1 1 1 1 11,500 36 Patients waiting for diagnostics 8,924 - 8,352 7,500 37 % of Patients waiting over 6 weeks for diagnostics 40% 22.8% 10 11 10 8 UHSFT Teaching hospital average (& rank of 20) 8 7 9 7 7 7 7 7 7 5 4 5 5 7 5 6 5 5 5 4 5 5 6 5 12.8% South East average (& rank of 18) 0% ≤5% 37 - As of April 2024, YTD and Monthly Target changed from 1% to 5% to reflect latest guidance YTD 43 9 8,352 11.1% Appendix YTD target 0 0 0 - ≤5% Page 13 of 17 Report to Trust Board in September 2024 Outstanding Patient Outcomes,Safety and Experience Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 100% Cancer waiting times 62 day standard - Urgent referral to first definitive treatment (Most recently externally reported data, 39 unless stated otherwise below) 67.0% 13 10 15 6 9 7 6 4 3 7 4 9 74.5% 7 6 UHSFT Teaching hospital average (& rank of 20) South East average (& rank of 17) 7 3 6 1 2 3 2 2 1 3 3 5 5 6 40% 39 - From October 2023 data onwards, the 62 day standard metric published in NHS england data combines Urgent Suspected Cancer and Breast Symptomatic with previously excluded Screening and Upgrade routes. As of April 2024, YTD and Monthly targets changed to 70% in line with latest operational guidance 100% Cancer 28 day faster diagnosis Percentage of patients treated within 40 standard UHSFT Teaching hospital average (& rank of 20) 80.9% 7 6 1 2 3 3 1 2 2 2 2 80.8% 2 2 5 3 1 1 1 1 1 1 1 1 1 5 6 South East average (& rank of 17) 50% Monthly target ≥70% ≥77% 40 - As of April 2024, YTD and monthly targets changed from 75% to 77% in line with latest operational guidance 31 day cancer wait performance - 100% 93.9% 93.4% decision to treat to first definitive treatment (Most recently externally reported data, 15 13 13 11 15 13 14 11 10 11 15 14 11 11 41 unless stated otherwise below) UHSFT Teaching hospital average (& rank of 20) 11 5 8 9 6 14 9 8 10 6 8 7 13 13 South East average (& rank of 17) 78% ≥96% 41 From October 2023 data onwards, the 31 day standard metric published in NHS england data combines First Treatment and Subsequent Treatment routes. YTD 73.7% 83.7% 90.2% Appendix YTD target ≥70% ≥77% ≥96% Page 14 of 17 Report to Trust Board in September 2024 Pioneering Research and Innovation R&D Performance 43 Comparative CRN Recruitment Performance - non-weighted Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug target YTD 25 19 19 21 17 17 16 15 15 15 15 9 9 9 Top 10 - 7 6 44 Comparative CRN Recruitment Performance - weighted 0 15 12 14 15 12 11 12 11 11 8 9 10 10 6 Top 5 - 9 11 0 150% 45 Study set up times - 80% target for 100% issuing Capacity & Capability within 40 59% 64% 46% 60% 67% 46% 88% 55% 50% 64% 50% 55% 100% 47% 44% - - 50% Days of Site Selection 0% 200% 157.6% Achievement compared to R+D 150% 104.1% 133.3% 133.3% 119.5% 90.2% 46 Income Baseline Monthly income increase % 100% 84.7% 50% 9.2% 45.8% 84.7% 65.2% 75.0% 26.8% 70.7% 18.0% 51.2% ≥5% - YTD income increase % 0% Appendix YTD target - - - - Page 15 of 17 Report to Trust Board in September 2024 Integrated Networks and Collaboration Appendix Local Integration Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Monthly target 250 194 Number of inpatients that were 47 medically optimised for discharge (monthly average) 0 201 ≤80 Emergency Department 48 activity - type 1 This year vs. last year 13000 11000 11,379 10,710 11,236 - 11,089 9000 Percentage of virtual appointments as a 49 proportion of all outpatient consultations This year vs. last year 40% 27.3% 29.4% 20% 29.4% ≥25% 24.9% YTD 214 58,989 25.9% YTD target - - ≥25% Page 16 of 17 Report to Trust Board in September 2024 Foundations for the Future Appendix Digital Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Monthly target My Medical Record - UHS patient 200,000 50 accounts (cumulative number of accounts in place at the end of each month) 100,000 170,987 213,476 - 50000 My Medical Record - UHS patient 40000 51 logins (number of logins made within 30000 each month) 20000 31,905 40,858 - 51 - The YTD Figure shown represents a rolling average of MMR logins per month within the current financial year 3200 Average age of IT estate 52 Distribution of computers per age in years 3000 2000 1000 0 0 2580 725 945 1150 0 23 32 68 118 289 1940 1510 - 14 13 12 11 10 9 8 7 6 5 4 3 2 1 YTD 209,848 36,203 - YTD target - - - 99.75% 99.72% 99.73% 99.81% 99.77% 99.82% 99.74% 99.79% 99.80% 99.79% 99.77% 99.78% 98.67% 98.64% 98.70% CHARTS system average load times - % 100% 53 of pages loaded under 3s 95% 53 -Data only available from April 2023 onwards. From April 2024 , metric was changed from % loading times under 5s to % loading times under 3s Page 17 of 17
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2024-Trust-documents/Finance-and-Performance-Reports-2024-25-Month-5-August-2024.pdf

Patients choosing doctors

Description: Governments encourage patients to believe they have choice, which may extend to the identity of their surgeon. Irrespective of whether this choice is illusory, patients often negotiate this system successfully.
Url: /HealthProfessionals/Clinical-law-updates/Patients-choosing-doctors.aspx

Papers Trust Board - 13 May 2025

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

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