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Annual report 20-21

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

Hydration Pilots application and support pack process

Description: January Classification: Official Hydration Pilots: Application support pack & process Hydration Pilots: application support
Url: /Media/Southampton-Clinical-Research/Grants/Download/Hydration-Pilots-application-and-support-pack-process.docx

Patients and staff to hold 'superhero day' to boost children's ED appeal

Description: Patients, staff and visitors are calling for community superheroes to come forward and boost the fundraising appeal for a new children's
Url: /AboutTheTrust/Newsandpublications/Latestnews/2018/April-2018/Patients-and-staff-to-hold-superhero-day-to-boost-childrens-ED-appeal.aspx

Papers Trust Board 27 May 2021

Description: Date Time Location Chair Agenda Trust Board – Open Session 27/05/2021 9:00 - 13:00 Microsoft Teams Peter Hollins 1 Ch
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2021-Trust-document/TB-papers/Papers-Trust-Board-27-May-2021.pdf

Annual report 2021-2022

Description: 2021/22 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2021/22 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2022 University Hospital Southampton NHS Foundation Trust Table of contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 36 Directors’ report 37 Remuneration report 59 Staff report 72 Annual governance statement 94 Quality report 105 Statement on quality from the chief executive 106 Priorities for improvement and statements of assurance from the board 109 Other information 182 Annual accounts 210 Statement from the chief financial officer 211 Auditor’s report 212 Auditor’s report including audit certificate 218 Foreword to the accounts 220 Statement of Comprehensive Income 221 Statement of Financial Position 222 Statement of Changes in Taxpayers’ Equity 223 Statement of Cash Flows 224 Notes to the accounts 225 5 Welcome from our chair and chief executive As we emerged from the most severe phase of the COVID-19 pandemic, 2021/22 was another challenging year for everyone at University Hospital Southampton NHS Foundation Trust (UHS). It was also a year on which we can look back with pride at what we achieved together in unprecedented circumstances. Amongst many notable achievements over the past twelve months, we have: • Led on globally ground-breaking research trials to inform the country’s COVID-19 vaccine booster strategy, including the world’s first COVID-19 vaccine booster study of mixed schedules. • Successfully managed infection prevention and control, putting us amongst the best in the country for minimising nosocomial spread. This was against a backdrop of, at times, R-rates in our local community that were amongst the highest in the country. • Published new strategies for digital and sustainability, which respectively set out how we are revolutionising our technical capability to meet changing patient needs and responding to the growing threat posed by climate change as part of the NHS-wide commitment to reaching carbon net zero by 2045. The pandemic also highlighted the vital importance of our staff’s wellbeing so we could continue to meet the needs of the most vulnerable and sick within our community and beyond. In response, we launched and have sustained a comprehensive programme of support to help our staff recognise and address the physical and emotional burden of the last two years. In financial terms, the Trust achieved its forecast breakeven position in 2021/22 on a turnover of £1.15 billion. Our strong, long-term financial performance meant we could continue investing in the capacity and condition of our estate. During the last year we have welcomed patients into our new ophthalmology outpatients area, expanded the majors area of our emergency department, built Hamwic House for treating cancer patients and opened four new operating theatres. Our ambition remains to increase capacity and improve facilities so that we can meet rising demand for our services, treating more people in improved settings than ever before. The momentum we are building is informed and driven by our five-year strategic plan, which describes our collective ambitions on our journey to becoming a world-class organisation. Our successes over the last twelve months were set against a backdrop of exceptional pressure on our services, unlike anything we have seen before. Like most hospital trusts, the lifting of COVID-19 restrictions in the wider community saw significant increases in attendances at our emergency department and increased referrals for treatments including surgery and cancer care. Everyone at UHS is working hard to restore services and bring waiting times down, although there are headwinds impacting our elective recovery. As we write this report, we have more than 200 patients in the hospital who no longer need our care but are waiting for discharge, either to a care home or to their own home with domiciliary care packages. Like many sectors, our local authority partners are struggling to buy or directly provide the capacity that is needed due primarily to workforce shortages. On occasion, the number of patients stranded in our hospitals means we have had to cancel scheduled surgery patients due to a lack of beds. Despite this, we are making good progress on recovering our elective performance, for example the number of elective surgery procedures in May 2022 was over 8% higher than in May 2019, prior to the COVID-19 pandemic. 6 Looking back over the year, our achievements would not have been possible without every single one of our 13,000 staff, who have gone above and beyond to put patients first. As a Trust Board we recognise that our people are our greatest asset. The results of this year’s NHS annual staff survey are encouraging, with the percentage of staff recommending UHS as a place to work being the sixth highest across all NHS trusts in England. However, we know we can do even better and our new people strategy will help us achieve this by introducing programmes which enable our people to thrive, excel and belong in a diverse and inclusive environment. We ended the year by saying farewell to Peter Hollins, who completed his second and final term as chair on 31 March 2022. In the six years of his leadership, the Trust has undergone a huge transformation to the benefit of both patients and staff. Peter has been a trusted and respected colleague whose outstanding leadership has set UHS on course to be a world-class organisation with world-class people delivering worldclass care. We welcome the formation of the Hampshire and Isle of Wight integrated care system on 1 July 2022, which will facilitate increased integration and collaboration across health and social care partners. We look forward to continuing strong relationships with all our partners as we work to develop an NHS of which all the communities we serve can be proud. Jane Bailey Interim Chair June 2022 David French Chief Executive Officer June 2022 7 OVERVIEW AND PERFORMANCE Performance report Introduction from our chief executive 2021/22 is the second year that the ways in which the Trust has worked, and the performance it has achieved, have been strongly influenced the COVID-19 pandemic. Our circumstances varied significantly through the year, however, by March 2022: • COVID-19 related restrictions had been removed across the wider community, but remained necessary within healthcare settings; • a combination of partial immunity and improved treatments had reduced the numbers of patients experiencing the most severe symptoms of COVID-19, but the total numbers of people being infected remained very high; and • the numbers of patients attending, or being referred to, healthcare services for other conditions had returned to pre-pandemic levels or higher. Our challenges and priorities have varied through the year in a similar manner, and have included: • providing sufficient urgent care capacity for patients with COVID-19 alongside those with other illnesses or injuries; • running our services with significantly increased levels of COVID-19 related absence amongst our staff, as infection rates have increased in the wider community; and • increasing the numbers of elective treatments provided, back to pre-pandemic levels and higher, to start to reduce patient waiting times and reverse the increases in waiting list sizes caused by COVID-19. Our performance this year has often been impacted by the adversity of the circumstances. We have not always been able to achieve the targets established prior to the pandemic, nor to deliver the standard of service that we would aspire to for our patients. The Trust is proud to have performed well in comparison to other hospital trusts across many performance measures, however, I would like to thank our patients for their understanding and patience, and all our staff for their resilience, commitment and dedication to care for patients and their colleagues. As we begin to emerge from the pandemic, and consider the year ahead, we look forward to working with patients, hospital colleagues, and partners across health and social care to: • continue the recovery from the impacts of the COVID-19 pandemic; • improve our performance against key measures, continuing to perform well in comparison with other hospitals and moving closer to the national targets; and • continue to adapt and improve services such that the outcomes and results achieved for patients will be better than ever before. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1 billion in 2021/22. It is based on the coast in south east England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to more than 3.7 million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and in the top ten nationally for research study volumes as ranked by the NIHR Clinical Research Network. 12,000 Every year over staff at UHS: treat around 160,000 inpatients and day patients, including about 75,000 emergency admissions see over 650,000 people at outpatient appointments deal with around 150,000 cases in our emergency department deliver more than 100 outpatient clinics across the south of England, keeping services local for patients The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it offers a safe, ‘home away from home’ environment for women having a healthy pregnancy and expecting a straightforward birth. The NHS patient services provided by the Trust are commissioned and paid for by local clinical commissioning groups (CCGs) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Just under half of the Trust’s NHS patient services are paid for by CCGs and just over half are paid for by NHS England. We provide these under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by Monitor (the independent regulator, now part of NHS England and NHS Improvement) and the healthcare services we provide are regulated by the Care Quality Commission. Being a foundation trust has enabled greater local accountability and greater financial freedom and has supported the delivery of the Trust’s mission and strategy over a number of years. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Public and foundation trust members Council of Governors Board of Directors Executive Directors Division B Division C Division D Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology 11 Trust Headquarters Division Always Improving Central Operations Clinical Outcomes Commercial Development Communications Contracting Corporate Affairs Data and Analytics Education and Workforce Estates, Facilities and Capital Development Finance Health and Safety Human Resources Informatics Medical Examinerss Service Occupational Health Organisational Development Quality Patient Safety Planning and Productivity Procurement and Supply Research and Development Safeguarding Strategy and Partnerships The Trust is also part of an integrated care system in Hampshire and the Isle of Wight, which is a partnership of NHS and local government organisations working together to improve the health and wellbeing of the population across Hampshire and the Isle of Wight. Our values Our values describe how we do things at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. Our values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to continue on its journey to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these it describes a number of ambitions we aim to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care Pioneering research • We will recruit and enable people to deliver pioneering research in and innovation Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the tax payer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2021/22 these objectives included: • Recovery restoration and improvement of clinical services • Introducing a robust and proactive safety culture • Empowering and developing staff to improve services for patients • Implementing the ‘Always Improving’ strategy • Delivering the first year of the research and investment plan • Restoring a full research portfolio and preparing for future growth • Delivering joint research and innovation infrastructure with UoS and Wessex partners • Increasing our people capacity (recruitment, retention, education) • Great place to work including focus on wellbeing • Building an inclusive and compassionate culture • Working in partnership with the integrated care system and primary care networks • Integrated networks and collaboration • Creating a sustainable financial infrastructure • Making our corporate infrastructure (digital, estate) fit for the future to support a leading university teaching hospital in the 21st century • Recognising our responsibility as a major employer in the community of Southampton and our role in delivering a greener NHS. Performance against these objectives will be monitored and reported to the Trust’s board of directors on a quarterly basis. Principal risks to our strategy and objectives The board of directors has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2021/22 were that: • It would have insufficient capacity to respond to emergency demand, reduce waiting lists for planned activity and provide diagnostics results in avoidable harm to patients • It would not be able to provide service users with a safe, high quality experience of care and positive patient outcomes • It would not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection • It would not secure the required ongoing investment to support our pioneering research and innovation, driving clinical services of the future 14 • It would not realise the full benefits of being a University teaching hospital through working with regional partners to accelerate research, innovation and adoption; increasing the number of studies initiated and the patients recruited to participate in these studies and the delivery of new treatments and treatments that would not otherwise be available to patients • It would not be able to increase the UHS workforce to meet current and planned service requirements through recruitment to vacancies and maintaining annual staff turnover below 12% and develop a longerterm workforce plan linked to the delivery of the Trust’s corporate strategy • It would not develop a diverse, compassionate and inclusive workforce, providing a more positive staff experience for all staff • It would not create a sustainable and innovative education and development response to meet the current and future workforce needs • It would not implement effective models to deliver integrated and networked care, resulting in suboptimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • It would be unable to deliver a financial breakeven position and support prioritised investment as identified in the Trust’s capital plan within locally available limits (CDEL). • It would not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. • It would fail to introduce and implement new technology and expand the use of existing technology to transform our delivery of care through the funding and delivery of the digital strategy. • It would fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045 While the COVID-19 pandemic presented the Trust with new risks as it introduced more stringent infection control processes, stopped certain types of activity and responded quickly to care for large numbers of seriously ill patients who had tested positive for COVID-19, it also prompted innovation across a wide range of areas. However the ongoing impact of the pandemic on both our staff, patients who have had COVID-19 and patients who have waited longer than expected for treatment as a result, have added to the risks facing the Trust. This risk has continued into 2021/22 and has been coupled with increases in referrals for cancer and increased attendances to our emergency department and non-elective activity. National targets for performance have not been amended as a result of the pandemic, although the national plan has focussed on the recovery of activity levels as the first stage in a restoration of elective services. Capacity – The initial and subsequent waves of the COVID-19 pandemic have led to increases in the waiting times for patients and the number of patients waiting more than 52, 78 and 104 weeks has increased significantly. While there was a significant reduction in the number of patients waiting over 104 weeks in 2021/22, with the Trust expecting that no patients will be waiting more than 104 weeks by July 2022, its ability to reduce the overall waiting list and the length of time patients are waiting for treatment remains one of the key risks for the Trust. This may be compounded by future waves of the COVID-19, a continuation of the sustained demand for urgent non-elective activity and an ongoing number of referrals, often requiring more complex treatment due to delays in people visiting their GPs for the first time and presenting with more advanced disease. The Trust utilised the support available from the independent sector to continue cancer treatment and surgery for those patients at highest risk and continues to make use of independent capacity for cardiac surgery. It also increased the number of outpatient attendances which took place by telephone or video call. The Trust developed a clinical assurance framework during the year to better assess the risk of harm to patients as a result of delays in treatment and this has been utilised in decision-making around the allocation of resources to those areas where there is the greatest risk of potential harm to patients. In addition to opening additional capacity during 2021/22 (described in the Estates section below), the Trust also committed expenditure in 2021/22 to open further wards and operating theatres during 2022/23 and 2023/24. These initiatives will contribute to further improvements in elective waiting times in coming years. 15 Quality and compliance – The Trust continued to monitor the quality of care delivered throughout 2021/22. During the COVID-19 pandemic the primary focus became infection prevention and control, with the launch of an award-winning COVID ZERO campaign that saw the Trust reduce the transmission of the virus in hospital (nosocomial transmission). While the Trust continued to perform well overall, the Trust exceeded its annual threshold for Clostridium difficile infections and there was one MRSA bacteraemia during March 2022, the only such event in 2021/22. The Trust continued to develop its proactive patient safety culture during 2021/22 with changes to the way in which patient safety incidents are investigated and the launch of its Always Improving strategy and transformation initiatives in theatre efficiency, patient flow and outpatients. Reporting and investigation of incidents continued during 2021/22. The Trust continues to prepare for the implementation of the new patient safety incident response framework in June 2022/23. Partnerships – During 2021/22, the Trust and its partners continued to work together to discharge patients safely, to ensure patients requiring urgent cancer treatment and surgery were able to continue their treatment in the independent sector and to develop the regional COVID-19 saliva testing programme for local schools, hospitals and other employers. The new arrangements for integrated care systems will be implemented in July 2022. This is expected to reinvigorate work with partners at a system, place and provider level in Hampshire and Isle of Wight. The Trust is already part of an acute provider collaborative with other acute trusts in Hampshire and the Isle of Wight and is progressing a number of projects including the development of an elective hub at Winchester Hospital, diagnostics, pathology, endoscopy and imaging networks. The Trust also continued to progress research activity and opportunities with the University of Southampton and Wessex health partners. Workforce – The Trust continued to recruit nurses from overseas and through targeted recruitment campaigns during 2021/22 meaning that the number of nursing vacancies has remained relatively stable. Vacancies in other areas have increased reflecting a more competitive job market, particularly for lower band roles. The Trust also continued to work with its staff networks and specific focus groups to increase diversity in leadership roles. Staff turnover remained above the 12% target during 2021/22 and retention is a key element of the people strategy. While workforce capacity continues to be one of the biggest challenges faced by the Trust, during 2021/22 we have also focused on supporting our staff to respond to the COVID-19 pandemic and operational pressures by providing both the tools and time to help staff recovery. We are incredibly proud of the way that staff responded to the pandemic and continue to recognise this in whatever ways we can, however, we also want to ensure that staff continue to be able to contribute to patient care at their best and want to stay and develop with the Trust. Technology was also used at levels not previously achieved to continue to deliver training to staff and enable staff to work from home where possible, ensuring a safer environment for patients and staff in the hospitals. Estate – The Trust continued to invest in and develop its estate during 2021/22 including opening a new ophthalmology outpatient area, expansion of the majors area of the emergency department and four new operating theatres. These were part of £65 million of capital expenditure in 2021/22 that also included equipment, digital and the backlog maintenance programme. Innovation and technology – There have been exceptional levels of achievement in relation to COVID-19 related research activity, including in partnership with the universities. You can read more about these in part three of the quality account. The board of directors has also supported the funding of an expansion of research and innovation activity to allow the continued delivery of the Trust’s ambitions to innovate and improve and transform its services. 16 The Trust and its partners also been successful in securing external funding including one of only four successful NHSX awards to test the concept of federated trusted research environments with its Wessex health partners and core funding of £10.5 million for the National Institute for Health and Care Research (NIHR) Southampton Clinical Research Facility (CRF) for the period between September 2022 and August 2027. Sustainable financial model –The Trust achieved its forecast breakeven position in 2021/22. Income was more predictable in 2021/22 as block contract arrangements remained in place in response to the COVID-19 pandemic and ensured that costs were covered, however, funding from the elective recovery fund, particularly, in the first half of 2021/22 introduced a degree of income volatility as did changes to the framework for the elective recovery fund half way through the year. The Trust continues to maintain a strong cash position and to implement improvements and efficiency savings, allowing it to continue to invest in its services. The financial outlook across the NHS looks extremely challenging going into 2022/23 due to the reductions in non-recurrent funding and efficiency targets. The Trust currently has an underlying deficit, with pressures on energy prices and drugs cost growth within block contract arrangements, which had been supported with non-recurrent funding in previous years. While specific funding has been provided to address inflationary pressures there is a risk that inflation could exceed this funding and raw material and supply shortages could also impact on costs. Performance overview The Trust monitors a very wide range of key performance indicators within its departments, divisions, directorates and executive committee. Assurance for our board of directors and executive committee includes an integrated performance report which is reviewed monthly and contains a variety of indicators intended to provide assurance regarding implementation of our strategy and that the care we provide is safe, caring, effective, responsive and wellled. The integrated performance report also includes a monthly ‘spotlight’ section, to enable more detailed consideration of any topics that are of particular interest or concern. The selection of topics is informed by a rolling schedule, any performance concerns and requests from the board of directors. Assurance for our council of governors includes a quarterly Chief executive’s performance report, which includes a range of non-financial and financial performance information. 17 Performance analysis COVID-19 Impacts In 2021/22, the most prominent impacts of COVID-19 have been in relation to occupancy of inpatient beds by patients with a COVID-19 diagnosis and increased levels of staff sickness absence associated with COVID-19, in addition to normal levels of absence due to other causes. The impact of COVID-19 has varied significantly through the year, linked primarily to the prevalence of the disease within the wider community. In comparison to 2020/21: • bed occupancy (all types) did not reach the same exceptional peaks, however, it exceeded 50 patients between August 2021 and March 2022 and reached an average of 83 in March 2022; • the number of patients requiring treatment in intensive care and high care were much reduced, though still significant; • fewer patients were admitted requiring hospital treatment for COVID-19 alone, and greater numbers were admitted requiring treatment for other medical conditions who were also infected with COVID-19 at the same time; • staff sickness absence levels were typically higher, particularly in the second half of the year when national restrictions had been removed and COVID-19 infections in the community increased – the sickness absence rate (from all causes) peaked at 6% in March 2022 All bed types Intensive care/higher care beds 18 Staff sickness absence Emergency access through our emergency department Following a reduction during the first year of the pandemic, the numbers of patients who presented to receive care at our emergency department increased exponentially in 2021/22. Attendance levels exceeded the higher levels seen prior to the pandemic by approximately 10%. All patients presenting to the emergency department This exceptional increase in the clinical demand upon our department has had a significant adverse impact upon the timeliness of care, particularly for those patients who have a less urgent condition. The department has also continued to deliver services separately for those patients who have respiratory symptoms and those who do not, and to implement additional infection control measures. Emergency access performance is measured as the percentage of patients discharged from emergency department care or admitted to a hospital bed within four hours of arrival to the department. The national target of 95% was not achieved and the Trust experienced a large deterioration in our own performance to 64% (main ED/Type 1 attendances) by March 2022. Our performance compared favourably with other acute trusts in England despite this, however. 19 Emergency access four hour performance The number and duration of any ambulance handover delays are another important performance indicator. Ensuring that ambulance staff can ‘hand over’ the patients they convey to our emergency department without delay is important because this releases the staff and their vehicle to meet the needs of other medical emergencies in the community. We are very proud to have an exceptionally good record in this regard, working with colleagues in ambulance services to transfer arriving patients into our emergency department and the care of our staff even when the hospital is already fully occupied. 20 Elective Waiting times Demand 2021/22 has seen a continuation of the trend of increasing elective referrals, following a major reduction which occurred at the start of the COVID-19 pandemic. Referral rates to our services are now typically at, or above, the levels seen before the pandemic. Feedback from clinicians is that they are also seeing more patients with advanced disease than they would normally, because of delays in referral to the service/diagnosis. Accepted referrals The number of patients referred to hospital with suspected cancer increased exceptionally during 2021/22; the number of patients seen for a first consultant-led appointment was 27% higher than in 2020/21 and 18% higher than in 2019/20. Performance remained below the national target of 93% throughout the year, with a deterioration to 74% in December 2021 prior to a recovery to 90% in March 2022. Our performance also declined in comparison with other acute trusts in England. Most of the patients who waited longer than two weeks for their first appointment were within our breast service, which sees a very large number of referrals for suspected cancer and experienced a 22% increase in the number of patients seen compared to 2019/20. Additional consultants who specialise in breast cancer have now been recruited and performance in this service returned to target in April 2022. 21 Performance following ‘Two week wait’ urgent referral for suspected cancer 22 Activity The number of UHS hospital appointments, diagnostic tests and elective admissions all increased significantly during 2021/22. The number of appointments undertaken, and diagnostic tests performed, exceeded activity levels in both 2019/20 and 2020/21. The number of elective and day case admissions increased significantly compared to 2020/21 (the first year of the pandemic) yet remained approximately 10% below the levels achieved between April 2019 and February 2020 (prior to COVID-19). There were a wide range of factors influencing these activity levels, and the lower levels of admitted activity specifically, including: • the availability of beds for the admission of elective patients after emergency patients with COVID-19 and other conditions had been accommodated; • the availability of staff to deliver elective care, during periods of increased COVID-19 bed occupancy, and during periods of increased staff absence related to COVID-19; • additional infection prevention measures which were maintained, particularly within inpatient treatment settings where risks of COVID-19 transmission are otherwise increased. Most of the activity has been delivered within NHS hospitals in 2021/22 (local independent sector hospitals were used to replace NHS elective capacity in 2020/21), and we have recruited additional staff and invested in an additional ward, theatres and outpatient rooms in order to be able increase our treatment activity. The graphs below show 2021/22 activity levels as a percentage of those achieved prior to the COVID-19 pandemic. Elective admissions (including day case) 23 Outpatient attendances Diagnostics Our performance measures for diagnostics report on a total of 15 different frequently used tests. At the end of March 2022, 20% of patients were waiting more than six weeks to receive their investigation. This is a significant improvement compared to 28% of patients waiting more than six weeks at the end of March 2021, yet still significantly worse than the national target (1%) and UHS performance prior to pandemic. At the end of March 2022, the total waiting list size (including patients waiting less than six weeks) had increased by 14% compared to March 2021 and was 34% larger than before the pandemic. These trends reflect a combination of large reductions in diagnostic activity in the first year of the pandemic, followed by record levels of diagnostic tests being performed during 2021/22 (7% higher than before the pandemic) combined with very high levels of referrals for diagnostic testing over the same period. 24 The tests with largest numbers of longer waiting patients are non-obstetric ultrasound, peripheral neurophysiology, MRI and CT. Initiatives to improve performance include the recruitment of additional staff in the relevant professions and investment in additional equipment, in the context of NHS forecasts that diagnostic demand will continue to increase over the longer term. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) Percentage of patients waiting over 6 weeks for a diagnostic test to be performed 25 Referral to Treatment Our waiting list from referral to treatment increased in size by 27% (9,768 patients) during 2021/22 and is now 36% larger than before the pandemic. Both referrals and hospital activity declined steeply at the start of the pandemic, but referral levels increased more quickly than hospital activity following this. The rate at which the waiting list is increasing has however reduced in the most recent six months. Number of patients waiting between referral and commencement of a treatment for their condition The national target is that at least 92% of patients should be waiting for treatment no more than 18 weeks from their referral to hospital. Our performance has deteriorated from 80% immediately before the pandemic, to 68% at the end of March 2022. Our performance continues to be typical of the major teaching hospital trusts that we benchmark with, and the trend has been similar to that experienced across trusts in England. Percentage of patients waiting up to 18 weeks between referral and treatment 26 The fact that some patients wait significantly longer than the 18 week target is a particular concern. In 2020/21 NHS England targeted the stabilisation of the numbers of patients waiting more than 52 weeks and the elimination of waiting times more than 104 weeks (except when patients choose to wait longer). The percentage of patients waiting more than 52 weeks at UHS reduced from 9% to 4%. The number of patients waiting more than 104 weeks reduced, from a maximum of 171, to 59 at the end of March 2022 (of whom only five were wishing to proceed with treatment at that time). The patients who typically wait longest for treatment continue to be those who require admission for surgical procedures in specialities such as ear nose and throat, orthopaedics and oral surgery. The Trust opened four additional operating theatres during 2020/21 and is working in collaboration with partners in the Hampshire and Isle of Wight integrated care system to implement further elective recovery plans. Percentage of patients waiting more than 52 weeks, between referral and commencement of a treatment for their condition 27 Cancer Waiting Times The timeliness of urgent services for patients with suspected cancer has unfortunately declined during 2021/22. The Trust continues to perform well in comparison with the teaching hospitals that we benchmark with and deliver a similar range of services, however. We have faced a range of challenges including: • a large increase in the number of new patients referred for investigation; • delays in the onward referral (for specialist investigation or treatment) of patients from other trusts which have also experienced increases in referrals; • the need to provide capacity to investigate and treat the full range of other conditions, alongside those patients with suspected cancer; and • an increase in the complexity of treatment required by new and existing patients, potentially because of delays in referral or treatment during the first year of the pandemic The national target is to provide the first definitive treatment to at least 85% of patients with cancer with 62 days of referral to hospital. UHS exceeded this level of performance in April 2021 but has not done so since then, performance deteriorated to 66% in January 2022 before recovering somewhat to 72% by March 2022. Treatment for Cancer within 62 days of an urgent GP referral to hospital The national target is to provide the first definitive treatment to at least 96% of patients within 31 days of a decision to treat being made and agreed with the patients. Trust performance has been very variable in 2021/22, ranging from 89% to 98% in individual months. Likewise, performance has ranged from below average in some months, to amongst the best in the group of teaching hospitals that we benchmark with. 28 First definitive treatment for cancer within 31 days of a decision to treat A range of initiatives are being pursued to maintain and improve the timeliness of our cancer services including: • changes to some of the processes for the referral and initial assessment of patients with suspected cancer, for example the inclusion of high quality photographs within referrals for suspected skin cancer; • projects to refine processes and procedures for the investigation of suspected gynaecological and urological cancers; • an operating services improvement programme designed to improve the flow of patients, and the numbers of patients treated, through our existing theatre facilities; and • staffing level increases and recruitment to clinical roles in specialities where the increases in demand require this. Quality priorities The Trust set four quality priorities in 2021/22, which were aimed at ensuring we continued to deliver the highest quality of care. The quality priorities were shaped by a range of national and regional factors as well as local and Trust‐wide considerations. We recognised the overriding issues of significant operational pressures being felt right across the health and social care system, including those associated with the second year of the COVID-19 pandemic, by limiting the number of priorities to four. We also acknowledged the risk that the delivery of our priorities could be disrupted by the ongoing pandemic and that we needed to be flexible in adapting the priorities to changing circumstances. The Trust set the following four priorities: 1. Introduction of midwifery continuity of carer for women at risk of complications in pregnancy. 2. To support staff wellbeing and recovery. 3. Managing risks to patients delayed for treatment and restoring elective programmes. 4. Reducing healthcare associated infection (HCAI) 29 The Trust achieved three of the quality priorities and partially achieved one priority. In relation to midwifery continuity of carer, the Trust’s performance exceeded the ambition that had been set by NHS England in 2020/21 following its national review of maternity services in 2015 as shown below. NHS England ambition set in 2020/21 35% of women will be booked to receive care in a continuity of carer team 35% of black and minority ethnic women booked to receive care in a continuity of carer team 35% of women living in an IMD-1 area (most deprived areas measured using indices of deprivation) Percentage achieved 41.7% 75% 80% The Trust continued to introduce programmes, interventions and wider support offerings to promote staff wellbeing and recovery in 2021/22. Our 2021/22 annual NHS staff survey results are positive with our scores relating to wellbeing above the benchmark average. Contributing factors to wellbeing such as staff engagement, morale, staff experience in areas such as kindness and respect, feeling valued and trusted to do their job were all above the benchmark average. More information about staff health and wellbeing is included in the staff report below. The Trust only partially achieved the priority relating to managing the risks to patients delayed for treatment and restoring elective programmes. The Trust’s performance against elective waiting time standards are described in more detail above. While the Trust focused on prioritising all patients waiting for surgery to ensure we continued to treat people based on need and urgency, we continue to recognise the impact of delays on people’s quality of life and, at times, outcomes. COVID-19 remained a key area of focus for the Trust in 2021/22 in terms of infection prevention. The Trust implemented a number of awareness campaigns, including its award-winning COVID ZERO campaign, and strategies to reduce in-hospital transmission of COVID-19 and kept these under review throughout the year. The chart below shows the trend of hospital-onset cases of COVID-19, which has broadly followed local and national prevalence of the virus, and the Trust’s performance compared very favourably with its local and national peers. 30 The table below provides an overview of the Trust’s performance against national and other infection prevention standards and limits to minimise infections, the majority of which have been achieved by the Trust. Category National Objectives: MRSA bacteraemia Clostridium difficile infection E coli Bacteraemia End of year RAG Action /Comment R One MRSA bloodstream infection attributable to UHS 2021/22 in March 2022. R 74 cases against a threshold of 64 for the year. G 138 cases in 2021/22 against a threshold of 151. Klebsiella Bacteraemia A 64 cases in 2021/22 against a threshold of 64. Pseudomonas Bacteraemia MSSA G 30 cases in 2021/22 against a threshold of 34. 43 cases in 2021/22 after 48 hours in hospital. Other: Hospital onset, healthcare associated COVID-19 103 hospital-onset probable healthcareassociated cases in 2021/22. 125 hospital onset definite healthcare associated cases in 2021/22. Prudent antibiotic Antimicrobial prescribing Stewardship G The standard contract requirement for reduction in antibiotic usage for 2021/22 was waived, as in 2020/21. Had it been applied as anticipated, the Trust would very likely have met this. Provide Assurance of Infection G The annual infection prevention audit assurance of Prevention Practice programme was reinstated in April 2021 for basic infection Standards the monitoring and assurance of infection prevention prevention and control practices but practice: subsequently suspended in September 2021. You can find more information about how the Trust delivered and measured its quality priorities, including feedback from patients and staff and improvement aims and quality priorities for 2022/23, in the Trust’s quality account for 2021/22, incorporated in the Trust’s annual report and accounts. 31 Financial performance The Trust delivered a surplus of £0.048 million from a revenue position of over £1.2 billion, once items deemed as “below the line” by NHS England and NHS Improvement, su
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-2021-2022.pdf

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

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

Description: This factsheet explains what an ultrasound scan is and what will happen at your child's appointment, so that you know what
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Laboratory medicine user handbook rev 22

Description: University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook re
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Southampton experts to perform UK's first MRI-led freezing procedure for prostate cancer

Description: Clinicians at Southampton's university hospitals are set to become the first in the UK to treat prostate cancer using frozen needles
Url: /AboutTheTrust/Newsandpublications/Latestnews/2017/June-2017/Southampton-experts-to-perform-UKs-first-MRI-led-freezing-procedure-for-prostate-cancer.aspx

Your child's polysomnography sleep study and multiple sleep latency test - patient information

Description: This factsheet contains information about having a polysomnography (PSG) sleep study and a multiple sleep latency test (MSLT).
Url: /Media/UHS-website-2019/Patientinformation/Childhealth/Your-childs-polysomnography-sleep-study-and-multiple-sleep-latency-test-2820-PIL.pdf

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