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MP000 028 Cellular pathology user handbook v24

Standing Financial Instructions

Description: These Standing Financial Instructions (SFIs) are issued for the regulation of the conduct of Trust members and officers in relation to all financial matters with which they are concerned.
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Finance/StandingFinancialInstructions.pdf

Papers Trust Board - 10 September 2024

Description: Agenda Trust Board – Open Session Date 10/09/2024 Time 9:00 - 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd Apologies Diana Eccles (10:00-12:00) In attendance Jessica Bown, Midwifery Quality Assurance and Safety Matron (shadowing Gail Byrne) 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 25 July 2024 9:15 Approve the minutes of the previous meeting held on 25 July 2024 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:20 Dave Bennett, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:25 Committee (Oral) Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee (Oral) 9:30 Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:35 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Patient Safety and Quality of Care in Pressurised Services 9:55 Review and discuss the report Sponsor: Joe Teape, Chief Operating Officer Attendee: Duncan Linning-Karp, Deputy Chief Operating Officer 5.6 Performance KPI Report for Month 4 10:05 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Finance Report for Month 4 10:30 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.8 Break 10:40 5.9 People Report for Month 4 10:55 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.10 Guardian of Safe Working Hours Quarterly Report 11:10 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Emergency Medicine Consultant and Guardian of Safe Working Hours 5.11 Learning from Deaths 2024-25 Quarter 1 Report 11:25 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience 5.12 Medical Appraisal and Revalidation Annual Report including Board 11:40 Statement of Compliance Receive and note the Annual Report. Approve the Statement of Compliance. Sponsor: Paul Grundy, Chief Medical Officer 5.13 Safeguarding Annual Report 2023-24 11:55 Receive and discuss Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Corinne Miller, Named Nurse for Safeguarding Adults/ Danielle Honey, Named Nurse for Safeguarding Children 6 STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update 12:10 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair's Actions Report 12:20 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Health and Safety Annual Report 2023-24 12:25 Receive and discuss Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Jane Fisher, Head of Health and Safety Services 7.3 People and Organisational Development Committee Terms of Reference 12:35 Review and approve Sponsor: Steve Harris, Chief People Officer 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 5 November 2024 10 Items circulated to the Board for reading 10.1 CRN: Wessex 2024-25 Q1 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 3 Minutes Trust Board – Open Session Date Time 25/07/2024 9:00 – 13:00 Location Anaesthetic Seminar Room (CE95/99)/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Jenni Douglas-Todd, Chair (JD-T) Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Tim Peachey, NED (TP) (until 12:00) Joe Teape, Chief Operating Officer (JT) Alison Tattersall, NED (AT) Natasha Watts, Interim Deputy Chief Nursing Officer (NW) (for G Byrne) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.3) Kelly Kent, Head of Strategy and Partnerships (KK) (item 6.1) Marie Nelson, R&D Head of Nursing and Health Professions (MN) (item 6.2) Karen Underwood, Director of R&D (KU) (item 6.2) Kerrie Montoute, Head of Programmes, CDO Directorate at NHSE (shadowing JDT) 1 member of the public (item 2) 3 governors (observing) 3 members of staff (observing) 2 members of the public (observing) Apologies Gail Byrne, Chief Nursing Officer (GB) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Gail Byrne. The Board welcomed Alison Tattersall, who joined the Board as a non-executive director on 1 June 2024. The Chair provided an overview of her activities since June 2024, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Patient Story Georgia Blackman and her parents were invited to relate their story following Georgia’s admission with serious head and abdominal injuries after a car accident in November 2023. She had not been expected to survive, but had instead made Page 1 a very good recovery and was undergoing rehabilitation and had regained some sight. The family related their experience of being told that their daughter was going to die and the importance of how this message is delivered was highlighted. It was further noted that where a patient is between 16 and 18 years old it was necessary to consider whether they are managed as a child or as an adult in terms of their care. 3. Minutes of the Previous Meeting held on 6 June 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 6 June 2024. 4. Matters Arising and Summary of Agreed Actions It was noted that there were no matters arising or overdue actions. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee The chair of the Audit and Risk Committee was invited to provide an overview of the meeting held on 27 June 2024 and the subsequent meeting of a committee authorised to approve the final annual report and accounts for 2023/24 held on 16 July 2024. It was noted that the annual report and accounts had been submitted to NHS England on 19 July 2024 and that the Trust’s external auditor had provided a ‘clean’ audit opinion. 5.2 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to provide an overview of the meeting held on 22 July 2024. It was noted that: • The committee had reviewed the Finance Report for Month 3 (item 5.8). • The committee had examined the Trust’s progress on its transformation programme, and noted in particular the success in reducing length of stay by 5% for P0 patients as part of the discharge programme. • The committee received a report on the Trust’s productivity and noted that the national methodology used created a confusing position and did not incorporate the impacts of certain factors which should be included. • The committee reviewed the Trust’s activities in the digital space and noted that capital in this area was primarily used for maintenance rather than development and that there was a significant infrastructure risk due to the Trust’s current data centre set up. It was further noted that better understanding of the benefits of digital development and timescales was required. • The Trust had agreed to participate in establishing a separate legal entity to seek investment to exploit intellectual property rights jointly developed by the Trust and the University of Southampton. 5.3 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to provide an overview of the meeting held on 22 July 2024. It was noted that: • The committee reviewed the revised People Report for Month 3 (item 5.9), noting that the workforce plan was at risk if there was no reduction in patients having no criteria to reside and mental health demand. • The committee had reviewed the Trust’s Employee Relations activities and received an update on an investigation into comments made on social media. Page 2 5.4 5.4.1 5.5 • In its review of the Board Assurance Framework (item 6.3), it was agreed that culture also needed to be reflected in the people-related risks. Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to provide an overview of the meeting held on 15 July 2024. It was noted that: • In its report from the Quality Governance Steering Group, the committee noted that there were two new never events under investigation. In addition, there were national shortages of certain medicines. The committee also noted an increase in violence and aggression linked to the increasing number of patients with mental health issues. • The committee reviewed the Fundamentals of Care programme and noted that it was very comprehensive. • The committee also received updates following a visit by Southern Health and the impact of demand by patients with mental health issues on the Trust. • The committee also noted a report by the Royal College of Radiologists on the Trust’s radiotherapy department, which provided positive feedback, and noted the expansion in use and scope of the service. • In its review of the Board Assurance Framework (item 6.3), the committee noted that the risk of staff availability could be due to both unaffordability as well as national lack of availability of qualified individuals. Action Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Maternity and Neonatal Safety 2024-25 Quarter 1 Report The chair of the Quality Committee was invited to provide an overview of the Maternity and Neonatal Safety 2024/25 report for the first quarter, the content of which was noted. It was further noted that: • Under the terms of the NHS Resolution Maternity Incentive Scheme, the Board had delegated review of the report to the Quality Committee. • There had been sustained improvement in meeting the required timescales for booking of appointments and screening since April 2024. • The continuity of carer need should be focused where it could make the most difference. • Appointment of a community partner by the Integrated Care Board was expected soon. • The Trust was approximately 40 members of staff short. However, plans were in place to address this deficit, including use of newly qualified nurses on rotations and the 36 new entrants expected between November 2024 and March 2025. Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • David French had met with the new Secretary of State for Health and Social Care on 19 July 2024 where the Secretary of State had outlined his priorities in terms of urgent and emergency care and addressing the backlog in elective care through using private sector capacity. In addition, it was noted that the intention for the longer term was to focus on preventative health and digital. • Following the General Election, there were also a number of new Members of Parliament for the area served by the Trust. Page 3 • On 1 July 2024, the new pathology laboratory information management system had been rolled out across the region. There had been some initial issues with providing information to primary care providers. • David French had been asked and had agreed to remain as the provider representative on the Hampshire and Isle of Wight Integrated Care Board until September 2024. • A new referral system for Ophthalmology had been launched, which would use A/I in supporting the booking process. 5.6 Performance KPI Report for Month 3 Joe Teape was invited to present the Performance KPI Report for Month 3, the content of which was noted. It was further noted that: • The Trust’s performance was in the top quartile for six out of nine measures and the top half for two others. • There had been a fairly stable period with better occupancy levels and improvements in timings of discharges. • There were ~220 patients no longer meeting criteria to reside during June 2024, and the Trust was considering a new plan with local partners for a local system delivery plan. • The Trust’s cancer performance continued to be impacted by the challenge posed by increasing demand. • The Trust’s performance against the 31-day standard had fallen to the third decile, with capacity issues in radiology and prostate services. • Further understanding of who was being referred under cancer pathways was required, as this could identify health inequality concerns in terms of who was accessing the Trust’s services. • Increases in referrals could be due to national campaigns which raise public awareness of certain forms of cancer and the possible symptoms. 5.7 Break 5.8 Finance Report for Month 3 Ian Howard was invited to present the Finance Report for Month 3, the content of which was noted. It was further noted that: • Nationally, the NHS’s deficit was above £1bn, representing 4-5%. The Hampshire and Isle of Wight Integrated Care Board had recorded a £57m deficit (6%) for month 3. The average deficit for university teaching hospitals was 4.1%. • The Trust had recorded a £13m deficit (year-to-date) and an in-month deficit of £4.5m. • There had been some early signs of improvement with the underlying position having improved since month 1. • The Trust’s elective recovery performance was 128% and there had been improvements in length of stay. • The Trust’s workforce numbers and pay costs were below plan, and agency numbers had halved since summer 2023. • The underlying monthly deficit was c.£5m, with approximately £1m of this attributable to unfunded pay awards and costs of industrial action. • Meeting the Trust’s plan for Quarter 2 of 2024/25 was expected to be challenging, as it assumed that the Integrated Care System’s transformation programmes would begin to deliver. • The Trust’s cash reserves were now below £30m, and the Trust might need to consider the need for additional cash from NHS England. • The Trust would continue to focus on its transformation programmes. Page 4 • The level of the anticipated pay award for 2024/25 and a likely shortfall in funding for the award was a risk to the Trust’s financial position. 5.9 People Report for Month 3 Steve Harris was invited to present the People Report for Month 3, the content of which was noted. It was further noted that: • A number of improvements were in the process of being made to the report to incorporate a ‘heat map’ and provide additional focus on culture. • The Trust was under its overall workforce plan by 313 whole-time equivalents (WTE) at the end of June 2024. However, in terms of its overall plan, ~200 WTE were reliant on improvements in the non-criteria to reside and mental health position. • Violence and aggression remained a key concern, with increasing use by the Trust of its warning and exclusion policy. • Work was ongoing to review the number of statutory and mandatory training courses with a view toward rationalising the number. • The ‘We Are UHS’ Champions award ceremony was to be held in October 2024. • The Integrated Care Board recruitment control panel appeared to be limiting the number of requests for recruitment likely due to improved filtering taking place by the individual trusts. 5.10 Annual Complaints Report 2023-24 Natasha Watts was invited to present the Annual Complaints Report for 2023/24, the content of which was noted. It was further noted that: • The number of complaints received had decreased slightly compared to the previous year, and the number of complaints upheld or partially upheld had decreased compared to the previous year and remained lower than the national average. • There had been four cases reviewed by the Parliamentary and Health Service Ombudsman, of which two were closed and two were partially upheld. • The overall quality of responses to complaints had improved. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2024-25 Quarter 1 Review Martin De Sousa was invited to present the Corporate Objectives 2024/25 Quarter 1 Review, the content of which was noted. It was further noted that: • The Trust’s performance was largely positive with 11 (out of 16) objectives on track to be delivered in full. • The major risks for achievement of the objectives were the Trust’s financial position and the possible impact of this on the workforce, and the Trust’s ability to reduce the number of patients not having criteria to reside. • Inclusion of a predicted future rating for each objective in reports was to be considered. Page 5 6.2 Research and Development Plan 2024-25 Karen Underwood was invited to present the Research and Development Plan for 2024/25, the content of which was noted. It was further noted that: • During 2023/24, the Trust had recruited its 250,000th participant and had launched its Research for Impact strategy. • Income for 2024/25 was predicted to be lower than previously due to the impact of Covid-19-related studies on prior years. • Vacancies and the reliance on clinical support services would be a challenge for 2024/25. Decision Having discussed the proposal, the Board approved the Research and Development Plan for 2024/25. Action Ian Howard agreed to obtain clarification regarding the discrepancy between the Return on Investment table and Appendix 4 in the plan. 6.3 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework, the content of which was noted. It was further noted that: • All risks had been reviewed by the Executive leads since June 2024. • The recorded gaps and controls were being checked and the BAF would differentiate between actions and aspirations in terms of the Trust’s steps to mitigate or address areas of risk. • It was intended to more closely link the BAF risks to the Board’s agenda. • The maturity assessment undertaken during 2023/24 as part of the audit of risk management carried out by KPMG would be reviewed to determine where the Trust would be against its aspirations by the end of the year. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (CoG) Meeting 24 July 2024 The Chair provided an overview of the meeting of the Council of Governors held on 24 July 2024. It was noted that the meeting had addressed the following matters: • The appointment of Shirley Anderson as the new Lead Governor. • Reports from the Chief Executive Officer and Chief Financial Officer. • The Trust’s annual report and accounts for the year ended 31 March 2024. 7.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 8. Any other business There was no other business. Page 6 9. Note the date of the next meeting: 10 September 2024 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 7 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 28/03/2024 4.14 Guardian of Safe Working Hours Quarterly Report 1127. Junior Doctors Grundy, Paul 24/10/2024 Pending Explanation action item Paul Grundy and Diana Hulbert agreed to include an item regarding junior doctors on a future Trust Board Study Session agenda. Due to industrial action on 27 June, this item has been deferred to the next TBSS on 24/10/2024. Trust Board – Open Session 06/06/2024 5.6 Performance KPI Report for Month 1 1152. Digital Teape, Joe Explanation action item JT agreed to include Digital as an agenda item at a future Trust Board Study Session. 24/10/2024 Pending This item is tentatively scheduled for TBSS on 24/10/2024. Trust Board – Open Session 25/07/2024 5.4 Briefing from the Chair of the Quality Committee (Oral) 1163. Impact of technology Machell, Craig 27/02/2025 Pending Explanation action item Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Update: Item tentatively scheduled for 27/02/25 Study Session. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 25/07/2024 6.2 Research and Development Plan 2024-25 1165. Discrepancy Howard, Ian 10/09/2024 Pending Explanation action item Ian Howard agreed to obtain clarification regarding the discrepancy between the Return on Investment table and Appendix 4 in the plan. Page 2 of 2 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose: Issue to be addressed: Response to the issue: Chief Executive Officer’s Report 5.4 David French, Chief Executive Officer 10 September 2024 Assurance Approval or reassurance Ratification Information X My report this month covers updates on the following items: • NHS Pay Offers • National Unison Campaign – Collective Pay Grievance for Healthcare Support Workers • Civil Unrest • Hampshire Together • Maternity Services and Sustainable Staffing • CQC Annual Hospital Inpatients Survey • Annual Regulation and Oversight Survey • Cass Review Implementation • Aseptic Preparation Audit • Human Tissue Authority inspection The response to each of these issues is covered in the report. Implications: Any implications of these issues are covered in the report. (Clinical, Organisational, Governance, Legal?) Summary: Conclusion The Board is asked to note the report. and/or recommendation Page 1 of 9 NHS Pay Offers On 29 July 2024, the Government announced that it would accept in full pay review body advice on NHS staff salaries and would make a pay offer to junior doctors in an attempt to end the ongoing industrial action. The Government accepted the 2024/25 recommendations of the NHS Pay Review Body for a 5.5% increase, backdated to 1 April 2024, for all Agenda for Change staff. This increase is expected to be reflected in October pay. In addition, intermediate pay bands will be created for Band 8 and 9 staff. In line with national guidance UHS will also offer back pay payments to be spread out over six months if individuals request this to help mitigate any impact on universal credit. The offer made to the junior doctors represents a 22.3% uplift over two years. This comprises an additional average of 4.05% for 2023/24 on top of the existing 8.8% implemented last year, taking the average uplift to 13.2%. In addition, 2024/25 pay would increase by an average of 12.4% against current 2023/24 payscales. The British Medical Association junior doctors committee recommends acceptance of this offer. Voting opened on 19 August and closes on 15 September 2024. The Government has also announced its intention to repeal the Strikes (Minimum Service Levels) Act 2023, which provides a mechanism to require workers in particular sectors, such as health, education, fire and rescue, and transport, to guarantee certain minimum levels of service during periods of industrial action. This will form part of a range of employment law modifications the government is considering, and the Board will be updated with further details once these are finalised. National Unison Campaign – Collective Pay Grievance for Healthcare Support Workers During August, UHS formally received a collective grievance relating to pay for Healthcare Support Workers (HCSWs). This is a national campaign led by UNISON pushing for recognition of duties carried out by these staff, formal re-grading of pay band, and appropriate back pay. UHS has over 1,200 individuals in these roles. The Chief People Officer is formally meeting with UNISON to discuss how the matter can be resolved. Whilst this is a national campaign, we have been told not to expect national resolution and Trusts have been directed to resolve locally as appropriate. Civil Unrest The nation experienced significant violent and racially motivated civil unrest during August. Farright anti-immigration rallies were planned in a number of cities across the UK, including Southampton. Healthcare workers had been directly targeted in some parts of the country by farright groups. This understandably generated fear and concern from our black, minority ethnic communities which was raised through various routes to leaders at the Trust. Communication was sent by the Chief Executive Officer and Chief Nursing Officer to all staff setting out our stance on the situation and proposed practical measures, coupled with local support from managers to those who were concerned. Led by the Chief Nurse through the Trust's incident management process, we rapidly implemented practical measures in addition to wider wellbeing and psychological support. Measures included additional security, additional transport and other local actions to help with people's safe journey to work on the day of planned demonstrations. Friday prayers were also attended by the Chief Medical Officer and the Director of OD and Inclusion to provide support to our Muslim communities. The unsavoury events have also triggered a collective drive to push again to focus on the violence and aggression issues at UHS. Staff still experience unacceptable violence, aggression and hate crimes by patients and service users at UHS and across the whole NHS. A multistakeholder workshop, including police partners, is planned for 2 October 2024 to re-energise Page 2 of 9 delivery of our existing commitments. We also want to use the expertise and advice of a range of people to explore and plan where we can go further and be bolder with this important agenda. At the national level, NHS England wrote to all integrated care boards, NHS trusts and foundation trusts, GP and dental practices, pharmacy contractors, and general ophthalmic service contractors on 12 August 2024 emphasising the NHS position that ‘discrimination is unacceptable, and the NHS should have a zero tolerance of racism towards our patients and colleagues’. NHS England also sets out some guidance in the following areas for organisations to listen to and support affected staff: • Ensuring staff can access the support they need • Involving staff networks in the organisational response • Dealing with instances of racism and discrimination • Demonstrating ongoing commitment to equality, diversity and inclusion The response can be read at: https://www.england.nhs.uk/long-read/nhs-response-to-2024-riots/ Hampshire Together HM Government has announced that it is pausing approval of the business cases for the ’40 new hospitals’, of which Hampshire Hospitals is one. Public consultation had recently been completed and submission of the final business case was anticipated before the end of this year but the timing of submission and approval of the business case is now uncertain pending the national review. Separately, the ‘Save Winchester Action Group’ has written to board members of HIOW ICB with concerns regarding the proposed changes at Winchester Hospital, specifically around the loss of acute services from the Winchester site. The overall programme was discussed at the ICS board meeting on 4 September 2024. The executive has a planned session with Hampshire Hospital NHS Foundation Trust executives at the end of September to discuss ideas around future models for services across all sites. Maternity Services Safe and Sustainable Staffing In August 2024, the Trust produced a briefing paper for the Care Quality Commission which provided a summary of the Trust’s action plan in respect of staffing of its Maternity services. The paper is attached as Appendix A. CQC Annual Hospital Inpatients Survey On 21 August 2024, the Care Quality Commission (CQC) published its adult inpatient survey for 2023. The survey examines the experiences of people over 16 who stayed at least one night in hospital during November 2023. The results showed a deterioration in people’s experiences of inpatient care since 2020, although the results for 2023 remained broadly consistent with those in 2022 and 2021. Most respondents reported a positive experience in their interactions with doctors and nurses, such as being treated with respect, dignity, kindness and compassion and being included in conversations. However, discharge from hospital remains a challenging part of people’s experience of care, with 29% saying that they had little to no involvement in decisions about their discharge, and only 48% saying that they were given enough notice about when they were going to leave. In addition, 23% of elective patients said they would have liked to have been admitted ‘a bit sooner’ and 19% ‘a lot sooner’, and 43% of elective patients believed that their health had deteriorated while waiting to be admitted. Page 3 of 9 The survey results can be viewed at: https://www.cqc.org.uk/publications/surveys/adult-inpatientsurvey Annual Regulation and Oversight Survey NHS Providers published the results of its annual regulation and oversight survey on 8 August 2024. According to the survey, trust leaders had reported an increased regulatory burden during the year, particularly noting a lack of coordination between regulators and questioning whether reporting requirements are proportionate or realistic. There were also questions as to whether regulators appropriately recognised the level of risks trusts had been absorbing in balancing the demands of financial and operational performance. Seventy-two per cent of trust leaders believed that the burden of integrated care board (ICB) regulation had increased, compared to 48% from NHS England and 36% from CQC. Less than a third of trusts were comfortable with the role of ICBs as performance managers and 62% saw their activity as duplicating that of NHS England. Respondents also questioned CQC’s credibility, feeling its judgements were not objective enough and inspection teams lacked sector-specific expertise. In addition, the majority of trust leaders would like to see a move away from the CQC’s one-word ratings, seeing it as too simplistic, often demoralising for staff, and confusing for patients. The survey report can be viewed at: https://nhsproviders.org/a-pivotal-moment-for-regulationregulation-and-oversight-survey-2024 Cass Review Implementation On 7 August 2024, NHS England published its plan to implement the advice from the Cass Review – the review of gender identity services for children and young people. This plan includes establishment of regional centres and changes to the referrals process to help trusts to deliver holistic, therapeutic and evidence-based care. The implementation plan can be read at: https://www.england.nhs.uk/long-read/children-andyoung-peoples-gender-services-implementing-the-cass-review-recommendations/ The Trust continues discussions with NHS England regarding whether Southampton could or should be one of these new regional centres. Aseptic Preparation Audit On 1 August 2024, the Trust was informed of the outcome of the external audit of unlicensed preparation of medicines for the pharmacy aseptic unit at Southampton General Hospital conducted on 4 June 2024. The unit’s operation was assessed as posing a low risk with respect to the quality of the medicines produced within it. The report also stated that the unit ‘is well managed and has good pharmaceutical quality systems in place’. Human Tissue Authority (HTA) inspection The HTA conducted an inspection of our mortuary arrangements in August. The formal feedback report has not been received but informal feedback has been shared by the inspection team. We expect the report to have no significant findings but we do anticipate a number of minor procedural and documentation recommendations. The inspection team advised us that the failings at Maidstone and Tunbridge Wells mortuary which enabled criminal activity to go unnoticed have triggered a recent ‘raising of the bar’, particularly regarding security / access arrangements. We will share the final inspection report when it is received, along with our response and action plan. Page 4 of 9 Appendix A UHS Briefing Paper to CQC Title: Maternity Services Safe and Sustainable Staffing Sponsor: Gail Byrne, Chief Nursing Officer Author(s): Emma Northover, Director of Midwifery Carly Springate, Head of Midwifery Marie Cann, Maternity and Neonatal Safety Lead Date: August 2024 Purpose: The purpose of this report is to note the current challenges in maternity staffing and provide assurance on the mitigations to maintain appropriate and safe staffing levels, which, in turn, ensures the delivery and support of high-quality care. Issue(s) to be addressed: Over recent weeks and months our Maternity Service has faced significant operational challenges, leading to more frequent than usual service diversions. This has led to impacts not only on the experience of our families and staff but across the wider Local Maternity and Neonatal System (LMNS). As from the beginning of July 2024, UHS Maternity Services have escalated to OPEL 4 on 23 occasions from the start of this year. Across the whole of 2023 OPEL 4 was declared 28 times. This shows a significant increase in service pressure that our Maternity Service is experiencing with staffing and acuity accounting for the majority of incidents. Whilst we are compliant with providing 1:1 care in active labour and we are safe, we are seeing an increase in other reportable red flags such as delays in induction and being unable to facilitate birthplace choices. In terms of our current position, staffing levels across the Maternity Service have remained challenging with vacancy rates across the registered workforce currently sit around 14%, equating to around 30 Whole Time Equivalents (WTE). Addressing these staffing challenges will require a coordinated effort and it is hoped that by collaborating with our partners we can develop a more comprehensive and effective approach to improving workforce provision. The enclosed plan of action sets out to address the staffing issues as much as possible until the newly qualified midwives start and vacancy is significantly reduced The DoM and the Senior Midwifery Leadership Team are committed to ensuring safe and sustainable staffing levels across UHS Maternity Services. We remain open and honest around our changing clinical environment as well as being sensitive and responsive to any rapidly changing picture. Escalation processes and frameworks are robust and well established. Further to this we have excellent engagement from our 1|Page Page 5 of 9 Maternity Safety Champions with whom we meet with regularly. This includes full support from Gail Byrne, Chief Nursing Officer and Executive Maternity Safety Champion, and Tim Peachey, Non-Executive Director and Maternity Safety Champion, who together ensure that the DoM has a platform and a voice at Trust Board. Despite the immediate challenges in respect of the Maternity Services workforce at UHS, we are looking to offer assurances to the CQC in terms of the actions both short and longer term that are being taken and the mitigations in place to reduce harm and maintain safety to our service users. Risks (top 3) of carrying out the change or not: Summary/ conclusion • 285 - Red 20 Maternity Staffing during peaks of activity • 259 - Red 16 Capacity and Demand in Maternity Services • 617 - Orange 12 Lack of postnatal care provision (staffing) • 815 - Red 15 Poor compliance with NICE guidance for Antenatal Bookings The CQC are asked to review this report and the mitigations in place and seek further assurance if required. Page 6 of 9 2|Page Maternity Staffing Action Plan Issue/Action Progress Lead Date 1. Following a successful newly • Our current preceptorship programme (18 months in hos- Practice Aug 2024 qualified midwife recruitment pital) has been recently reviewed in terms of content and Education lead drive, 34 WTE band 5 midwives structure to ensure that these staff are retained. to join UHS Maternity Services in November 2024. 2. Utilisation of contingency • Provides contingency measures in releasing and redeploy- Head of Aug 2024 framework ing additional staff. Midwifery RAG G 3. Utilise birthrate plus as a • The last assessment of UHS Maternity Services by BR+ in Director of framework for workforce planning 2018 suggested an overall clinical establishment based on Midwifery and strategic decision making a midwife V birth ratio of 1:24, calculated against an annual birth rate of 5500 births. This is soon to be recalculated Sept 2024 A 4. Increased staff support in the • We have retained 100% of our newly qualified preceptees Head of Aug 2024 G clinical environment in addition to who started with us in November 2023. Midwifery pastoral and psychological Practice support to enhance retention of Education Lead the workforce. 5. The senior leadership team, • To review how we maintain this going forward to ensure Director of Aug 2024 G including the Director of sustainability Midwifery / Chief Midwifery (DoM), commit to a Nursing Officer high number of out-of-hours on- calls to support the service when in escalation and when staffing does not match the acuity and activity across the acute clinical areas. 3|Page Page 7 of 9 6. Two fixed term matron roles have • This provides additional cushioning to the matron team and Director of been appointed to oversee a development opportunity for our existing workforce. Midwifery antenatal and postnatal pathways. 7. Development of a systematic • This live data is reflective of total staff unavailability in- Maternity process for workforce planning in clude vacancy rates, sickness ratios, maternity leave, and Business the form of a monthly dashboard. study time, all of which is compared alongside the budg- Support eted versus actual staffing establishment overall. Manager 8. The labour ward coordinator will • This enables the labour ward coordinator to have continu- Head of not take responsibility for any ous oversight of their clinical environment and oversee Midwifery patients, or cover breaks for other safety. members of staff. 9. An extensive listening exercise • To align with current service needs, and with staff wellbe- Director of has been undertaken place to ing as a central focus, the DoM and Senior Midwifery Midwifery help inform the future direction Leadership Team are reviewing the way the service is de- and structure of the Maternity livered with the potential of a workforce restructure. Service workforce. 10. 12 – 16 Registered nurses are to • Divisions seeking staff who are interested in supporting Director of be seconded to maternity in this and with the right skillset. Midwifery interim period to help release midwife time with roles such high • A review will be undertaken to see if this could be a dependency, vaccination, longer-term proposition to support the maternity workforce fundamentals of care 11. Dedicated programmes for career • Our prime focus is to consider new ways in which we can Director of development starting at band 2 future proof our Maternity Services going forward, whilst Midwifery and progressing to band 9. investing in our people. 12. A NHSP Incentive Scheme has been agreed to run over the summer months • This action has enabled staff to feel valued and appreciated Director of for all their gestures of good will and their contributions to Midwifery Page 8 of 9 Aug 2024 G Aug 2024 G Aug 2024 G Aug 2024 A Aug 2024 A Aug 2024 A Aug 2024 A 4|Page the workforce that are worked outside of contractual commitments. 13. A review to look at tipping points • Contact to be made with the ED to review learning and any Head of (as happens in Emergency processes and systems. Midwifery Department) to be scoped introduced 14. A roster review will be • Full review of the roster template to ensure fit for purpose Maternity undertaken to ensure the correct and staff allocated correctly. Business staffing levels and skills are in Support place. Manager Aug 2024 A Aug 2024 A 15. To introduce legacy midwives • Review of legacy midwives roles and recruitment Director of Aug 2024 A (recently retired midwives) to processes. Midwifery support newly qualified staff and Practice education Education Lead R Red: Immediate remedial action required A Amber: Action in progress G Green: Complete Page 9 of 9 5|Page Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose: Issue to be addressed: Patient Safety and Quality of Care in Pressurised Services 5.5 Joe Teape, Chief Operating Officer Duncan Linning-Karp, Deputy Chief Operating Officer 10 September 2024 Assurance Approval or reassurance X Ratification Information Urgent and Emergency Care (UEC) services are under significant pressure nationally, with some high-profile cases of poor care highlighted, including in the press. In response NHSE has asked Trust Boards to assure themselves that they are doing all they can to: • Provide alternatives to emergency department attendance and admission, especially for those frail older people who are better served with a community response in their usual place of residence. • Maximise in-hospital flow with appropriate streaming, senior decision-making and board and ward rounds regularly throughout the day, and timely discharge, regardless of the pathway a patient is leaving hospital or a community bedded facility on. Response to the issue: This paper will outline UHS’s response to the above issues, including the improvement programmes focused on flow and the Emergency Department, the response to the UEC recovery plan year two document, work taking place across the local system and mitigations that take place when the Emergency Department becomes over-crowded. Implications: Clinical, organisational, governance, legal (Clinical, Organisational, Governance, Legal?) Risks: (Top 3) of carrying out the change / or not: • Harm to patients in the Emergency Department through prolonged waits and / or overcrowding. • Harm to patients who remain in hospital longer than necessary because of delayed discharge. • Harm to patients on an elective waiting list who are delayed because of a lack of capacity due to high levels of patients not meeting the criteria to reside. Summary: Conclusion Trust Board is asked to note this report. and/or recommendation Page 1 of 10 Introduction NHS England wrote to all NHS Trusts (see Appendix 1) to ask Trust Boards to assure themselves that Trusts, and wider systems, were doing all they can to reduce demand on Emergency Departments, improve flow across the UEC pathways including out of hospital, ensure basic standards of care are in place across all care settings and ensure executive visibility and leadership, and non-executive presence. This paper provides assurance to the Board, addressing the key requests outlined in the letter and benchmarks UHS’s response to the year two UEC plan. It also outlines work taking place in the local system to support admission avoidance and reduce delayed discharge. Finally, it outlines mitigations the organisation has put in place to manage risk at times when the Emergency Department (ED) is overcrowded, and to support flow through the hospital. Patient Safety and Quality of Care in Pressurised Services NHSE wrote to all Trusts to outline key actions Boards were required to assure themselves on to ensure patient safety and quality of care is maintained in pressurised services. The table below outlines those actions and UHS’s compliance against them. Request Provide alternatives to emergency department attendance and admission, especially for those frail older people who are better served with a community response in their usual place of residence. Maximise in-hospital flow with appropriate streaming, senior decision-making and board and ward rounds regularly throughout the day, and timely discharge, regardless of the pathway a patient is leaving hospital or a community bedded facility on. Their organisations and systems are implementing the actions set out in the UEC Recovery Plan year 2 letter. Basic standards of care, based on the CQC’s fundamental standards, are in place in all care settings. Services across the whole system are supporting flow out of ED and out of hospital, including making full and appropriate use of the Better Care Fund. Executive teams and Boards have visibility of the Seven Day Hospital Services audit results, as set out in the relevant Board Assurance Framework guidance. There is consistent, visible, executive leadership across the UEC pathway and appropriate escalation protocols in place Assurance There are community alternatives in place, including Urgent Community Response and virtual wards. More work is taking place to set-up Integrated Neighbourhood Teams. In-hospital flow is something UHS is continuously seeking to improve via the inpatient flow programme, focusing on all aspects of flow within the hospital’s control and ensuring patients only remain in hospital when necessary. Ward rounds take place daily with appropriate input from a senior decision maker. UHS is compliant with these actions, outlined in the following section. Fundamentals of care standards have been rolled out across the organisation. A CQC Oversight Group, chaired by the CNO, provides assurance on compliance against the standards. The wider system does support flow out of ED and the wider hospital, and the Better Care fund is used. However, the system continues to struggle with a high number of patients remaining in hospital who do not meet the criteria to reside. Seven Day Hospital Services are reported via the annual Quality Account to the Board and the Trust is compliant. A further audit is due in 2024. There is consistent, visible executive leadership across the UEC pathway including a fortnightly ED meeting chaired Page 2 of 10 every day of the week at both trust and system level. Regular non-executive director safety walkabouts take place where patients are asked about their experiences in real time and these are relayed back to the Board. by the Chief Executive, a monthly UEC Board chaired by the COO, a monthly CQC Oversight meeting chaired by the CNO and regular executive walkabouts. UHS has an internal escalation plan as does the wider system. The Trust appointed a clinical Director for Urgent and Emergency Care. Non-executive directors undertake walkabouts as part of Trust Board. Year two UEC Plan Benchmarking against the second year of the UEC plan shows that UHS is compliant against the key metrics. There has, however, been a reduction rather than an increase in some out of hospital capacity because of the financial challenges facing the ICB, Local Authorities and wider system. Request 1A. Maintain acute G&A beds at the level funded and agreed through operating plans in 2023/24. 1B. Maintain ambulance capacity and support the development of services that reduce ambulance conveyances to acute hospitals. 1C. Focus on reduction in ambulance handover delays to support system flow. 1D. Expand bedded and non-bedded intermediate care capacity, to support improvements in hospital discharge and enable community step-up care. 1E. Improve access to virtual wards through improvements in utilisation, access from home pathways, and a focus on frailty, acute respiratory infection, heart failure, and children and young people. 2A. Focus on reductions in admitted and non-admitted time in ED. Assurance UHS’s 2024/25 plan included the dual aspirations of halving the number of patients not meeting the criteria to reside and reducing length of stay by 5%. If these were both met, it is unlikely that we would require all current beds. However, while beds that are not needed would not be staffed, they will remain available if needed. In recent months routine surge capacity has remained closed b
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2024-Trust-documents/Papers-Trust-Board-10-September-2024.pdf

Laboratory medicine user handbook rev 22

Description: University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 G3.7 Laboratory Medicine Laboratory medicine provides a comprehensive range of pathology services to the Trust, general practitioners and also to other external NHS and private sector organisations. It consists of clinical biochemistry, haematology, blood transfusion and immunology departments. Contents: - click the links or scroll down the page Key contacts Specimen transport About our services Adding additional investigations Availability of clinical advice Results reporting Telephoning of significant results Services offered Service hours Useful clinical information Quality assurance Completion of the request form Click on ‘laboratory medicine investigations’ or ‘pathology test information’ in the downloads section (on the right) for information on laboratory tests Specimen collection Special advice on sample collection Specimen rejection Click on ‘specimen rejection’ in the downloads section for the laboratory policy on sample rejection Click on ‘sample storage and disposal’ in the downloads section for details of sample retention times High risk specimens and safety Key contacts Results/General enquiries for all departments 023 8120 6464 labresults@uhs.nhs.uk Specific departmental contacts: If dialling from outside SGH preface 4 digit numbers with 023 8120, unless full number is given Clinical Biochemistry Helpline (24 hrs) 6427 Revision 22 Page 1 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 Clinical advice e-mail uhs.dutybiochemist@uhs.nhs.uk G3.7 Clinical director Dr Paul Cook 6419 Pathology Operations Director Consultant & Deputy Clinical Lead for Biochemistry Linda Sayburn Nicola Merrett 6435 6434 Lab Medicine Operations Rick Allan Manager 6706 POCT coordinator Haematology and Blood Transfusion Will Rivenberg 6721 Haematology Laboratory 4029 Coagulation Laboratory 4823 Blood Transfusion Lab 4620 Phlebotomy Supervisor Phlebotomy services SGH Clinical Lead Shamaila Tahsin Dr M W Jenner 4821 4874 4438 Laboratory Lead Dr M W Jenner 4438 Haematology Lab Director Dr Seonaid Pye 3162 Consultants Dr M W Jenner (Myeloma, Haematological Oncology, Blood and Marrow Transplantation) 4438 Dr S Narayanan (Myeloma, Haematological Oncology, General Haematology) 4438 Dr D S Richardson (Haematological Oncology, Blood and Marrow Transplantation) 6164 Dr K H Orchard (Haematological Oncology, Blood 4118 and Marrow Transplantation) Dr R S Kazmi (Haemostasis & Thrombosis, Blood 8862 Transfusion, General Haematology) Revision 22 Page 2 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 Dr Robert Lown Dr Sara Boyce Dr Tracy Burt (General Haematology) Wessex Immunology Service Immunology lab Flow Cytometry Immunology Clinic Consultant Immunologist Dr Efrem Eren Consultant Immunologist Dr Sapna Srivastava Consultant Clinical Scientist Dr Alison Whitelegg Consultant Clinical Scientist Dr Karen Smith-Baker Honorary Consultant Prof A Williams G3.7 3556 3556 5831 6615 6640 4001 6650 Mob: 07887812703 5929 2043 6976 6670 About our services Laboratory Medicine provides a comprehensive range of Pathology services to the Trust, General Practitioners and also to other external NHS and Private Sector organisations. Consent Please see the following document available on the UHS website: Consent to Examination or Treatment: Policy Patients attending adult venesection services will be asked to give verbal consent prior to blood specimens being collected. Information Governance All staff working for the Pathology have a legal duty to keep information about patients and staff members confidential and to protect the privacy of individuals. All staff adhere to the Trust’s Data Protection and Confidentiality Policy and are mandatorily required to perform annual Information Governance training. Dealing with Complaints Laboratory Medicine adheres to the Trust Policy for handling concerns and complaints. All complaints, either raised via Patient Support Services or directly to a member of staff from within the department will be thoroughly investigated and actioned to resolve any identified issues. Revision 22 Page 3 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust G3.7 LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 http://staffnet/TrustDocsMedia/DocsForAllStaff/GovernanceAndSafety/HandlingConcernsandComplai ntsPolicy/HandlingConcernsandComplaintsPolicy.pdf Availability of clinical advice Consultants within each discipline are available to provide help with the interpretation of results and other clinical advice. Please refer to 'Key Contacts'. Services offered Clinical Biochemistry provides a full range of laboratory and clinical services incorporating routine biochemistry, lipids, toxicology and metabolism, endocrinology, trace metals and the co-ordination of clinical trial work and point-of-care testing. Renal stone, lipid and bone outpatient clinics are also undertaken. Haematology and Blood Transfusion provide routine Haematology, Blood Transfusion and specialised haemostasis and haemoglobinopathy testing in support of regional and national programmes as well as services to support an expanding bone marrow transplant service. The department also supports a Haemophilia service for both adults and children. Consultant and nurse-led outpatient clinics are undertaken at SGH, RSH and Lymington Hospitals. Day care facilities are available on C3 Hamwic day ward at SGH and at Lymington Hospital. Palliative care is available through Countess Mountbatten House at Moorgreen Hospital. Immunology provides routine immunological analysis into allergy, autoimmunity and protein chemistry as well as specialised analysis for the diagnosis of haematological malignancy and immunodeficiency. Follow this link for Clinical Services Outpatient service details Venesection service - see detail in Service hours (below) Point of care testing. We can provide help and advice on the implementation of point of care testing system such as hand held blood glucose meters. Please contact our POCT coordinator for further information. Service hours Clinical Biochemistry, Haematology and Blood Transfusion laboratories 24-hour service List of tests available 24 hours a day in Haematology and Coagulation Haematology: FBC Retics Revision 22 Page 4 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 ESR G3.7 Glandular fever (IM) screen Blood film Malaria parasite screen Sickle cell test Coagulation: Coagulation screen (CS) INR APTR D-dimer derived fibrinogen Factor assays (with approval from Haematology consultant) G6-PD screen ADAMTS13 Specialist laboratories available Monday to Friday, 9am to 5pm Clinical Biochemistry / Haematology Immunology Blood Tests - Service locations and hours (April 2011) Phlebotomy services are available at Southampton General Hospital and Lymington Hospitals. Details of times and venues are given below: - Location Opening times SGH, C level, South Laboratory Block Monday to Friday,0800 to 1645. Appointments can be booked via www.uhs.nhs.uk/bloodtests SGH, children - Butterfly room, C level Monday to Friday by appointment only, Call 023 8120 2024 Lymington Hospital Monday to Friday, 0730 to 1645. Appointments can be booked via www.uhs.nhs.uk/bloodtests Revision 22 Page 5 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 Royal South Hants Community Monday to Friday 0800 to 1800 Diagnostics Centre Saturdays 0800 to 1530 G3.7 Appointments can be booked via www.uhs.nhs.uk/bloodtests Please note that appointments may be necessary for special procedures such as dynamic function tests Completion of the request form Request forms need to be properly completed. A request form must accompany all specimens sent to the laboratory and should clearly state the following information: • Surname and forename • Hospital /NHS Number • Date of birth • Sex • Ward/Clinic and Consultant code • Type of specimen • Date and time of collection • Investigations required • Relevant clinical information • Identification of priority status. eQuest (electronic requesting) is the preferred method for the requesting of tests in Chemical Pathology, Haematology, Coagulation and Immunology as it leads to quicker processing times and reporting. Specimen Collection Samples should be collected into appropriate tubes and sent to the laboratory. Please allow tubes to fill to capacity. This is especially true of coagulation, where underfilled samples are unsuitable for testing and will be rejected. The laboratories at SGH are open and able to receive samples 24 hours a day, 7 days a week. Samples should be clearly labelled with the patient's name and date of birth. A request form that provides patient information, specimen type and tests required should accompany samples. The requirements for samples for Blood Transfusion are more stringent, due to the prescription nature of the request. Both the sample and request should contain a minimum of the following information: • Full name (no abbreviations) Revision 22 Page 6 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 • Hospital number and/or NHS Number G3.7 • Date of birth • Date and time sample taken • Signature of person taking blood Failure to adhere to Blood Transfusion request guidelines WILL result in the rejection of the request, without exception. A table of specimen requirements for commonly requested tests is provided below: Test Anticoagulant Adult tube top colour Routine Biochemical profile, lipids, etc. Serum Separator Tube (SST) with Gel Gold Glucose Fluoride Oxalate Grey HbA1c EDTA Mauve FBC and ESR EDTA Mauve Coagulation Citrate Sky Blue Immunology investigations Serum Separator Tube (SST) with Gel Gold Lithium Serum Separator Tube (SST) with Gel Gold Group and Save/Crossmatch EDTA Pink NT-Pro BNP Lithium Heparin Green ACTH EDTA Mauve PTH Lithium Heparin Green HIT screen Serum Red For all the above tubes, please ensure that the maximum fill is attained. Failure to do this may mean that the laboratories are unable to perform certain tests. When using UHS electronic requesting system eQuest, it is imperative that the request-generated barcodes are of good quality (i.e. they are complete with a clear gap at either end), are attached to the correct sample and are attached straight, along the length of the tube, NOT around it. Failure to observe these instructions WILL lead to delays in processing and testing samples. Revision 22 Page 7 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 G3.7 Special advice on sample collection The information below is intended to provide advice on patient preparation and specimen collection for specific tests where results may be affected by these factors: Faecal Immunochemical Testing (FIT) Requesting source should contact the lab for FIT sampling kits and advice. Glucose Tolerance Test GTTs on Non-pregnant patients can be performed by the Venesectors in Pathology Outpatients. G.P.s who wish to use this service should send the patient, with a completed request form for a GTT to the Venesectors at Pathology Outpatients at 0845 on Monday, Tuesday, Wednesday and Friday morning. (Please note that Thursday is not possible due to large haematology clinics that morning.) Clinicians with hospital beds should arrange for their juniors to do the tests on the wards. In pregnancy GTT's are carried out at Princess Anne Hospital in the antenatal Day Unit by special arrangement, telephone 023-8079-6303. These are generally requested by the Obstetrician at P.A.H. The patient must have taken an unrestricted diet, including adequate carbohydrate, for at least 3 days prior to the test. The patient must be fasted for 10-16 hours before the test begins (plain water only allowed) and for the duration of the test. It is therefore convenient to commence the test first thing in the morning. Cryoglobulins Prior to taking a blood sample, please contact the immunology lab to collect a flask containing water maintained at 37°C. The sample must be taken and returned to the laboratory within 1 hour of the flask being collected in a plain tube (Red topped) and must arrive by 1.30pm to allow time for processing. Trace Elements sample requirements Urine samples Random urine samples/plain 24-hour urine aliquots should be collected into Sterilin universal containers or other suitable trace element-free containers. Whole blood samples 2mL Teklab lithium heparin tubes (paediatric samples) Greiner sodium heparin for Trace Elements Analysis Vacuettes (adult samples) External laboratories Revision 22 Page 8 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 G3.7 If sending serum/plasma samples, whole blood samples should be collected as stated above, and then spun and separated into trace-element free polycarbonate tubes (these should not have rubber gaskets/O-rings in the lid as they are sources of contamination). For any queries, please contact the Trace Elements laboratory: uhs.traceelements@uhs.nhs.uk Sweat tests Current Cystic Fibrosis unit sweat collection procedure Sweat Test Process • Identify patient • Select forearm (avoid cuts) • Cleanse skin with steret • Wipe skin with sterile water & gauze • Attach gel discs to each probe (only touch if wearing gloves) • Apply red probe to lower arm and secure with straps • Apply black probe to lower arm but higher than red probe • Switch machine on • Machine will beep when finished (after 5 mins) • Remove black probe • Remove red probe • Throw both gel discs away • Cleanse arm with sterile Water & Gauze • Attach collection plate to area previously covered by the red probe • Push down (should see blue dye appear to confirm working) • Secure with straps • Cover with bandage/cling film • Leave for 30 minutes or until 3-4 clear blue rings seen in window • Flip plastic cover off collection plate • Pull plastic tubing out of collection plate and cut at base • Use plunger to push sweat collected into collection pot • Put small collection pot into specimen bottle & send to Trace Elements lab with specimen form. N.B. We measure sweat chloride only in this laboratory. Creatinine Clearance test Collect a special urine collection bottle from the laboratory; this contains a small amount of thymol as a preservative. Patient empties bladder; discard this urine and note the time on the bottle. Revision 22 Page 9 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 G3.7 For the next 24 hours every drop of urine passed by the patient must be added to the bottle. Advise the patient to pass urine before opening their bowels if necessary. 24 hours later, empty bladder again and add to the collection, and note the time. The collection does not have to be exactly 24 hours, but we must know the exact times of starting and ending the collection (to the nearest minute). At any time during the urine collection take a venous blood sample into a lithium heparin tube for plasma creatinine estimation. Separate request cards must be written to accompany the urine sample and blood sample. 5-HIAA For 24 hours prior to starting the using collection patients should refrain from eating or drinking any of the items listed below or any food or drink containing these items: Broccoli, Cauliflower, Brussel Sprouts, Egg Plants, Mushrooms, Citrus Fruits and Tomatoes (including juices), Bananas, Avocados, Plums, Passionfruit, Pineapple, Alcohol (wine and beer), Processed meats (loaves, salami, sausages, ham), Fish, Seafood, Nuts, Seeds, Berries and Caffeine (including products containing chocolate). Specimen rejection Specimens will be rejected if they are unsuitable for the investigations requested or if the identity of the patient is in doubt. This is to prevent misleading results being reported that could lead to inappropriate patient management. The Laboratory Medicine specimen rejection policy contains full details and can be accessed using the link located in the downloads section of this web page. High risk specimens and safety All specimens must be collected into leak resistant containers. The container must be appropriate for the purpose, properly closed and not contaminated on the outside. All specimens are regarded as high risk, but if they are taken from a patient who is known to be infected with a blood-borne agent such as hepatitis B virus and HIV, another serious infectious disease such as tuberculosis or typhoid, or from those at risk of being infected by one of these agents, then extra care should be taken to highlight this. These specimens should be labelled as HIGH RISK on the request form. Specimen transport All sample containers from a single request are to be sealed into a clear plastic specimen bag by the person taking the sample. Specimen request forms/support documents must not be placed in the same compartment as the sample. UHS specimen transport arrangements: Samples are collected from wards on a frequent basis by the portering service. However, using the pneumatic tube delivery (POD) system improves sample turnaround times and reduces pressure on Revision 22 Page 10 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 G3.7 portering staff. The system cannot be used for blood and blood products for transfusion, nor for Cellular Pathology samples that are immersed in liquid formalin fixative. It should also not be used for: - · Sputum samples · CSF samples for xanthochromia (? SAH) The system should be used for all other Pathology samples including blood cultures. All samples for Laboratory Medicine should be sent to POD station number 8355 GP Practice specimen transport and collection arrangements: Samples are collected from surgeries and clinics on a daily basis. For details of frequency and times please contact: Transport Department 140 Mauretania Road Nursling Industrial Estate Southampton SO16 6YS Tel: 023 80748027 Adding Additional Investigations Immunology: Cell based assays only viable for 48 hours. Serological tests - please note that requests for retrospective testing can be made up to 3 weeks ONLY after the sample has been taken, subject to the sample volume remaining being sufficient and the nature of the retrospective request Clinical Biochemistry: Specialist Biochemistry, Endocrinology investigations: 3 weeks Automated investigations: 24 hours Trace Element: 1 Month Urine drug screen - one month Chromatography investigations: 1 month Blood Transfusion: Depends on 'sample validity '. A sample is valid for 7 days when stored at 4C as long as the patient has not been transfused in the last month. If patient has been transfused in last month, the sample is only valid for 72 hours from when the transfusion started or must not be more than 72 hours old when transfusion begins. Kleihaur can be added up to 7-days. Revision 22 Page 11 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 G3.7 Coagulation: Test to be added INR, CS, DD, Lupus Anticoagulant APTR Thrombophilia screen Factor assays, Protein C/S, Antithrombin, Thrombin Time, Von Willebrand antigen, Collagen Binding assay, Ricof, Platelet aggregation, PFA 100, Thromboelastogram, Any other specialist coagulation test Time limit 12 hours 4 hours Not possible to add 1 hour after venesection Not possible to add Automated Haematology: Test to be added FBC, IM (glandular fever) screen, Haemoglobinopathy screen, Sickle cell screen, Film, ESR, Reticulocyte, nucleated RBC Malaria parasite screen G-6-PD screen Time limit 1 day 1 day Needed fresh 1 day If the required investigation is not listed above, please contact the relevant laboratory Results Reporting • Validated results are reported electronically to UHS results servers eQuest and ICE. • Electronic reports are produced for GP sources every 2 hours 05:00-22:00 for delivery via EDI PMIP services. • Hard copy reports for valid locations are printed and dispatched every working day, including Saturdays. Telephoning of significant results Revision 22 Page 12 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 G3.7 Samples may be "fast tracked" and results telephoned back when necessary. Results for these samples will normally be available within 2 hours of receipt in the laboratory. Please call ext. 8890 and provide patient's details so that the sample may be identified. Occasionally unexpected abnormal results are produced. If this occurs, laboratory staff will endeavour to telephone these results to the requesting source. Useful clinical information Common causes of spurious results Please ensure that you follow instructions when collecting and storing samples. Inappropriate sample collection, storage and transport can interfere with a number of results. Same examples are given in the table below: Problem Common causes Effect Incorrect tube fill/mixing Delay in separation of plasma overnight storage delay in transit ALL analytes may be compromised Increased K, PO4, LDH Storage Biochemistry samples in a fridge Increased K Haemolysis Expelling blood through a needle into the tube Vigorous shaking Increased K, PO4, ALT, LDH, Mg, Iron Extremes of temperature Inappropriate collection site Sample taken from drip arm Increased drip analyte e.g. K , Glucose Dilution effect low results Incorrect container or anticoagulant No fluoride oxalate E.D.T.A. contamination Decreased glucose Decreased Ca Increased K Li sample collected into Li Heparin Increased Li Revision 22 Page 13 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 G3.7 Hormone profiles PROBLEM MALE PATIENTS Erectile dysfunction Infertility Gynaecomastia/ galactorrhoea FEMALE PATIENTS ? Menopause {?PCO; hirsutism;virilisation;alopecia Amenorrhoea/oligomenorrhoea Infertility Galactorrhoea APPROPRIATE REQUESTS LH FSH Prolactin Testosterone (08.00-10.00H) LH FSH Prolactin Testosterone (08.00-10.00H) LH FSH Prolactin HCG Testosterone (08.00-10.00H) Oestradiol; thyroid function tests (LFT's & renal profile) For women 11.1 mmol/L or 2) A fasting plasma glucose concentration > 7.0 mmol/L or 3) A 2-hour glucose post 75g oral GTT of > 11.1 mmol/L A GTT should not be necessary if the fasting plasma glucose is > 7.0 mmol/L, but this needs to be confirmed on another occasion if the patient has no symptoms. Patients with impaired fasting glycaemia ("IFG") (fasting plasma glucose > 6.1 but less than 7.0 mmol/L) should be assessed with an oral GTT. Impaired glucose tolerance ("IGT") is defined as a fasting plasma glucose of 7.8 but 5 mmol/L Possible causes (rare genetic causes excluded) Spurious 1. Haemolysed samples Revision 22 Page 15 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED. University Hospital Southampton NHS Foundation Trust LABORATORY MEDICINE G3.7 Laboratory Medicine user handbook rev 22 G3.7 2. Delay in separating plasma from cells - the ideal is within 1 hour of venepuncture. Values after 6 hours are unacceptable 3. Samples refrigerated at 4 C 4. Unusually cold weather - potassium leaks into plasma during transport 5. Collection into inappropriate tubes (e.g. fluoride tubes used for glucose; potassium EDTA tubes for blood counts) 6. Vigorous mixing 7. Patients open and close their fist repeatedly during venesection 8. Very high white cell counts: > 2000 x 109/L (leukaemias) 9. Very high platelet counts: > 1000 x 109/L 10. Abnormally permeability of red cells: cold agglutinins; infectious mononucleosis; inherited red cell membrane defect (rare) True hyperkalaemia Normal kidneys excrete excess potassium promptly - within hours. Hyperkalaemia generally occurs with renal failure plus another factor. Life-threatening hyperkalaemia is almost always encountered in those with impaired renal function. Drugs 1. Potassium supplements 2. Potassium sparing diuretics - triamterene; amiloride; spironolactone 3. Drugs that interfere with the renin/aldosterone axis: a. ACE inhibitors—e.g. captopril; enalapril b. ACE 11 receptor blockers- e.g. losartan; candesartan c. nonsteroidal anti-inflammatory drugs d. heparin; tacrolimus; cyclosporin; trimethoprim-sulphamethoxazole e. Drugs that inhibit membrane ATPase -digoxin; β-Blockers Combinations of the above are particularly risky Diet 1. Potassium-containing salt substitutes (low salt) 2. High potassium foods if end-stage renal failure Acute renal failure: Especially if catabolic—sepsis; injury; intravascular haemolysis; GIT bleed Chronic renal failure: If no other exacerbating factors potassium may be maintained until GFR 7.5 mmol/l) :muscle weakness; paraesthesiae; rarely: flaccid paralysis Risk increases with rising potassium but there is not close correlation - patients with chronic renal failure may be more resistant ECG abnormalities are the best guide to risk plasma potassium (mmol/L): rough correlation [1] 6.5-7.0 Peaked T waves [2] 7.0-8.0 Prolonged P-R interval; flattening then loss of P waves; Widening of QRS complexes with deep S waves [3] > 8.0 Sine wave pattern progressing to ventricular fibrillation then cardiac arrest [4] > 10.0 Generally fatal Can progress rapidly from [1] to [3], particularly if plasma sodium or ionised calcium is low Hyperkalaemia with peaked T waves is serious Hyperkalaemia with more advanced ECG changes is life-threatening Low plasma potassium 3.0 mmol/L Potassium supplements or potassium sparing drugs are advised with diuretics if: · pre-treatment potassium is 3.0 – 3.2 mmol/L · potassium falls to 3.0 – 3.2 mmol/L after 4 weeks on diuretics · the patient has a potassium-losing disorder (e.g. cirrhosis, nephrotic syndrome; chronic diarrhoea) Replacement of a serious body deficit takes a long time. Quality Assurance All Pathology departments have a mature quality management system, as described in the Pathology quality manual. The following departments are UKAS accredited medical laboratories: Department of Haematology & Blood Transfusion. UKAS accreditation number: 8149 Department of Clinical Biochemistry UKAS reference number:8483 Department of Immunology UKAS reference number: 8696 (The UKAS ISO15189 schedule of accreditation are detailed on the UKAS website https://www.ukas.com/find-an-organisation/ Please refer to the attached document G3.7a laboratory medicine investigations for the accreditation status of individual tests We are accredited for training Biomedical Scientists and Clinical Scientists by the Health Care Professions Council (HCPC). Revision 22 Page 19 of 19 IF THE FIRST PAGE OF THE PROCEDURE DOES NOT HAVE RED “APPROVED METHOD” STAMP IN THE FOOTER – THAT PROCEDURE PRINTED COPY IS UNCONTROLLED.
Url: /Media/UHS-website-2019/Docs/Services/Pathology/Lab-med/Laboratory-medicine-user-handbook.pdf

Papers Trust Board - 15 July 2025

Description: Agenda Trust Board – Open Session Date 15/07/2025 Time 9:00 - 13:00 Location Conference Room, Heartbeat Education Centre Chair J
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Papers-Trust-Board-15-July-2025.pdf

STH816 v1 Department of infection user handbook

Description: Microbiology and Specialist Virology Services User Handbook STH816/02-25 Issued Date 23.07.2025 Authorised by R. All
Url: /Media/UHS-website-2019/Docs/Services/Pathology/STH816-v1-Department-of-infection-user-handbook.pdf

Appendix A - Algorithm for the completion of monthly returns

Description: Algorithm for the completion of monthly returns for VZIG, HBIG200IU, HBIG500IU and RIG/rabies vaccine"PHE Colindale", "UHS
Url: /Media/UHS-website-2019/Docs/Post-Exposure-Prophylaxis-Policy/AppendixA-Algorithmforthecompletionofmonthlyreturns.pdf

UHS adult major trauma guidelines

Description: Adult Major Trauma Guidelines University Hospital Southampton NHS Foundation Trust Dr Mark Baxter Director of Major Trauma, Consult
Url: /Media/SUHTExtranet/WessexTraumaNetwork/UHS-adult-major-trauma-guidelines.pdf

Papers Trust Board - 9 September 2025

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 09/09/2025 9:00 - 13:00 Conference Room, Heartbeat Education
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Papers-Trust-Board-9-September-2025.pdf

Papers Trust Board - 13 May 2025

Description: Agenda Trust Board – Open Session Date Time Location Chair Apologies In attendance 13/05/2025 9:00 - 13:00 Conference Room, Heartbeat Educatio
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Papers-Trust-Board-13-May-2025.pdf

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