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Papers Trust Board - 15 July 2025

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Agenda Trust Board – Open Session Date 15/07/2025 Time 9:00 - 13:00 Location Conference Room, Heartbeat Education Centre Chair Jenni Douglas-Todd Apologies Alison Tattersall In attendance Lauren Anderson, Corporate Governance and Risk Manager (from 9:30) (shadowing Craig Machell) 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 13 May 2025 9:15 Approve the minutes of the previous meeting held on 13 May 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee 9:20 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee 9:25 Dave Bennett, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:35 Tim Peachey, Chair including Maternity and Neonatal Safety 2024-25 Quarter 4 Report and Maternity and Neonatal Workforce Report 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 2 10:10 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Break 10:40 5.8 Finance Report for Month 2 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICS Operational Delivery Report for Month 2 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 People Report for Month 2 11:10 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Freedom to Speak Up Report 11:20 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.12 Infection Prevention and Control 2024-25 Annual Report 11:30 Receive and discuss Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Clinical Lead, Department of Infection/Julie Brooks, Deputy Director of Infection Prevention and Control 5.13 Guardian of Safe Working Hours Quarterly Report 11:40 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 1 Review 11:50 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendee: Martin De Sousa, Director of Strategy and Partnerships 6.2 Research and Development Plan 2025-26 12:00 Discuss and approve the plan Sponsor: Paul Grundy, Chief Medical Officer Attendees: Christopher Kipps, Clinical Director of R&D/Karen Underwood, Director of R&D/Laura Purandare, Deputy Director of R&D Page 2 6.3 Board Assurance Framework (BAF) Update and Risk Appetite Statement 12:10 Review and discuss the update. Review and ratify the risk appetite statement. Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair's Actions Report 12:30 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Review of Standing Financial Instructions 2025 12:35 Review and approve the SFIs Sponsor: Ian Howard, Chief Financial Officer Attendee: Phil Bunting, Director of Operational Finance 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: 9 September 2025 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 15 July 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.6 Performance KPI Report for Month 2 5.8 Finance Report for Month 2 5.9 ICS Finance Report for Month 2 5.10 People Report for Month 2 5.11 Freedom to Speak Up Report 5.12 Infection Prevention and Control 2024-25 Annual Report 5.13 Guardian of Safe Working Hours Quarterly Report 6.1 Corporate Objectives 2025-26 Quarter 1 Review 6.2 Research and Development Plan 2025-26 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 1c 3b All 2a Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 4x5 20 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date 13/05/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Diana Eccles, NED (DE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Duncan Linning-Karp, Interim Chief Operating Officer (DL-K) David Liverseidge, NED (DL) Tim Peachey, NED (TP) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Ceri Connor, Director of OD and Inclusion (CC) (item 5.11) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Diana Hulbert, Guardian of Safe working Hours and Emergency Department Consultant (DH) (item 5.12) Kelly Kent, Head of Strategy and Partnerships (KK) (item 6.1) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.13) Natasha Watts, Deputy Chief Nursing Officer (NW) (item 5.13) Helena Blake, Head of Clinical Quality Assurance (shadowing G Byrne) Raquel Domene Luque, Interim Lead Matron, Ophthalmology (shadowing G Byrne) 1 governor (observing) 6 members of staff (observing) 3 members of the public (observing) Apologies Keith Evans, Deputy Chair and NED (KE) Alison Tattersall, NED (AT) 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 Keith Evans and Alison Tattersall. 2. Patient Story Item postponed to the next meeting. 3. Minutes of the Previous Meeting held on 11 March 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 11 March 2025. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. It was noted that action 1218 could be closed. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Ian Howard was invited to present the Committee Chair’s Report in respect of the meeting held on 17 March 2025, the content of which was noted. It was further noted that: • The committee considered the going concern assessment in respect of the 2024/25 annual accounts and agreed that it was appropriate that the accounts be prepared on a going concern basis. • The committee additionally noted that there had been no significant issues raised by the Trust’s external auditors. • The committee received a report on losses and special payments during 2024/25, noting that these payments generally related to lost patient property. • An update was received in respect of Information Governance. The Trust – in common with most others – was not expected to meet the standards set out in the Data Security and Protection Toolkit due to the introduction of the Cyber Assurance Framework as part of the Toolkit requirements. 5.2 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 March and 28 April 2025, the content of which was noted. It was further noted that: • The committee reviewed the Finance Report for Month 12 (item 5.8), noting that the Trust had achieved its forecast deficit of £7m for 2024/25 following the receipt of revenue support. Furthermore, the Trust had achieved £85.3m of Cost Improvement Programme delivery and Elective Recovery performance of 127%. Nonetheless, the Trust’s underlying deficit was circa £75m. • The Trust’s cash position remained challenging with the Trust likely to require revenue support during either the first or second quarters of 2025/26. • The committee reviewed the Trust’s proposed 2025/26 plan during March 2025 and noted that there were no material changes between the draft reviewed and that submitted on 23 April 2025. • The committee supported a proposal for the Trust to participate in the elective hub at Winchester. 5.3 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 March and 25 April 2025, the content of which was noted. It was further noted that: • The committee received a briefing in respect of the Staff Survey 2024 (item 5.11). • The committee reviewed the People Report for Month 12 (item 5.10), noting that the Trust had ended the year 373 whole-time-equivalents (WTE) above plan. This was largely due to the reductions in patients having no criteria to reside and mental health patients not materialising. In addition, there had been higher than normal use of bank staff in March 2025 and lower than anticipated staff turnover. Page 2 • An update in respect of the planned organisational restructuring, including regarding the Equality and Quality Impact Assessment process being developed. • It was considered likely that the delivery of the Trust’s 2025/26 workforce plan would necessitate additional workforce controls. It would be important to ensure that appropriate support was provided to staff in managing at a time of increased demand, financial pressures, and a reducing workforce. 5.4 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 17 March 2025, the content of which was noted. It was further noted that: • The committee reviewed the Trust’s quality indicators, which continued to indicate that the organisation was under pressure. • Following an incident at Derriford Hospital in Plymouth on 4 March 2022 whereby a member of the public had suffered fatal injuries due to the downwash from a landing helicopter, the Trust had commissioned a review of its own safety arrangements. It was noted that some additional safety measures would be required. • A visit by NHS South East Region to the Princess Anne Hospital in February 2025 had provided some positive feedback about the service. The Maternity and Neonatal Safety 2024/25 Quarter 3 Report was noted. It was further noted that: • The report had been reviewed by the Quality Committee at its meeting held on 17 March 2025. • The proportion of births via caesarean section remained high at over 40%, with late requests in particular placing additional pressure on theatre capacity. • Following successful recruitment of additional staff in late 2024, operational pressures had reduced substantially compared with the previous situation. • A never event relating to a missing swab was under investigation. • The Trust was currently over establishment in terms of its number of midwives and expected to be staffed above the requirement indicated by the anticipated birthrate for the area by the end of 2025/26. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • Significant reorganisations of NHS England and integrated care boards (ICBs) had been announced. NHS England was to be abolished, and certain functions merged into the Department of Health and Social Care. Integrated care boards were expected to have to reduce their costs by 50%. • A ‘model’ integrated care board blueprint had been published, which appeared to imply that a significant proportion of ICB functions could be redistributed to providers. • It was expected that the number of ICBs would reduce to 25-30, with each serving populations of c.2m. In Hampshire, ICB and local authority boundaries were expected to align, which was considered to be beneficial. • The British Social Attitudes Survey 2024 showed the lowest satisfaction rating for the NHS since the survey began. • The Spring Statement and subsequent messaging indicated that there would not be additional funding during 2025/26. • The Trust continued to face significant pressure due to patients having no criteria to reside. Historically, there were typically around 100 such patients at Page 3 any one time, whereas 281 had been reported on 13 May 2025. This was the equivalent of six wards. • The Trust faced significant financial pressure during 2025/26 with a lower financial settlement than expected. In order to meet its plans, the Trust would be required to deliver c.£110m of Cost Improvement Programmes, reductions of 5% in divisions and 10% in Trust Headquarters, coupled with clinical and non-clinical recruitment controls. The Trust continued to experience high demand for services, especially in the Emergency Department. • It was important to protect the frontline and assist the organisation with managing at such a time. 5.6 Performance KPI Report for Month 12 Duncan Linning-Karp was invited to present the Performance KPI Report for Month 12, the content of which was noted. It was further noted that: • The Trust continued to face significant challenges in terms of its Emergency Department performance, with only 57.2% of patients spending less than four hours in the main Emergency Department. An external review was to take place. • There had been a four-month trajectory of increasing numbers of falls. Whether there was any correlation between the increasing number of falls and number of patients having no criteria to reside was being investigated. • The Trust continued to report strong Elective Recovery performance, although the size of the Trust’s waiting list continued to increase. There was some concern as to whether the financial pressures were impacting elective performance and waiting times. • There had been a decrease in the number of virtual outpatient appointments. • Ten never events had been reported as of the end of March 2025. The Trust expected regulatory scrutiny as a result. • The metrics reported in respect of research and development were being reevaluated. Duncan Linning-Karp was invited to present the spotlight on the Mental Health Patient Cohort, the content of which was noted. It was further noted that: • Regular reports on mental health patients were provided to the Quality Committee. • During 2024, there were 347 patients with a decision to admit to a mental health bed whilst at UHS (2023: 303), of these only 13.2% were transferred within the expected 12 hours (2023: 18.5%). During the first quarter of 2025, there had been 92 such patients. If the numbers remained consistent for the rest of 2025, a growth rate of 6% was expected. • In terms of patients brought to the Emergency Department as a hospital-based place of safety detained under section 136 of the Mental Health Act 1983, only 22% of patients brought to the Trust had a physical need, whereas the remaining patients were brought to the Emergency Department due to the lack of an available facility. • There were insufficient beds available at mental health providers, who were also impacted by delayed discharges. • The enhanced care required by mental health patients placed significant demand on the Trust’s resources. The situation appeared to be worsening with around 100 patients at any one time, of which around 10 were acute. • The Trust has met with the Integrated Care Board and mental health provider to push for a working group to address the issue that care for mental health patients at the Trust cost significantly more than the cost for looking after Page 4 patients at a dedicated facility due to the need to engage specialist agency staff. Actions Duncan Linning-Karp agreed to investigate why the number of virtual outpatients appointments had reduced. Gail Byrne agreed to examine the trend in respect of the friends and family test negative score for inpatients. 5.7 Break 5.8 Finance Report for Month 12 Ian Howard was invited to present the Finance Report for Month 12, the content of which was noted. It was further noted that: • The Trust had delivered its forecast £7m deficit at year end. This had been achieved through a combination of additional Cost Improvement Programme (CIP) delivery and additional revenue support • Whilst the Trust had delivered £85.3m of CIP, a significant proportion of this was non-recurrent. The Trust continued to record an underlying deficit of £6- 7m per month. • The Trust had £17m in cash, below its usual minimum holding of £30m. The Trust continued to closely monitor and manage its cash position, but it was likely that support would be required in the first quarter. • During 2024/25, the Trust had carried out £34m of unpaid for activity, particularly in terms of Emergency Department, non-elective and outpatient follow ups. There were, however, limited opportunities to reduce this activity due to quality impacts . 5.9 ICB Finance Report for Month 12 Ian Howard was invited the present the ICB Finance Report for Month 12, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had achieved a breakeven position for 2024/25. It was noted that this represented a significant achievement given that the system was reporting a cumulative deficit of £80m at Month 5. • The system-wide transformation programmes had had a lower-than-expected impact on the Trust. 5.10 People Report for Month 12 Steve Harris was invited to present the People Report for Month 12, the content of which was noted. It was further noted that: • At year end the Trust was 373 WTE above its 2024/25 plan. There had been a significant increase in use of bank staff in March 2025 due to annual leave and the number of mental health patients. The size of the substantive workforce had, however, reduced, albeit at a lower level than expected. • The formal consultation in respect of the organisational changes had been commenced with the unions. The Trust would be moving from four to three divisions and reducing its workforce. • The Trust had announced its intention to reduce the size of its workforce by 780 WTE (c.6%). This was to be achieved via a combination of natural Page 5 attrition and vacancy control and through a Mutually Agreed Resignation Scheme. • There were a number of risks to achievement of the Trust’s 2025/26 workforce plan, including: quality and safety risks (mitigated through Equality and Quality Impact Assessment); a lower-than-expected turnover rate due to a lack of opportunities elsewhere; the Trust’s cash position; and delivery of non-criteria to reside and mental health patient reductions. • The Trust had released a statement to staff and was awaiting guidance in respect of the recent Supreme Court ruling regarding the definition of a woman under the Equality Act 2010. 5.11 UHS Staff Survey Results 2024 Report Steve Harris was invited to present the UHS Staff Survey Results 2024 Report, the content of which was noted. It was further noted that: • The results of the Staff Survey had been discussed in detail by the People and Organisational Development Committee on 24 March 2025 and at a Trust Board Study Session held on 1 April 2025. • The Trust benchmarked well in certain areas, such as recommendation as a place to work and in terms of views of line management. However, the response rate was lower than in previous years and violence and aggression and civility and dignity scores remained areas of concern. The Board discussed the results of the Staff Survey and agreed that the Trust should focus its efforts on violence and aggression and on helping staff to manage change. It was noted that there was a strong correlation between line manager engagement and the survey response rate. 5.12 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • There was to be a change in the exception reporting process from September 2025. The Trust was considering how best to manage these changes. • The financial constraints during 2025/26 would potentially impact the locum fill rate. • The Trust’s estate remained an issue, but work was ongoing, including consideration of re-purposing existing spaces. • Concerns had been expressed from some seeking consultant posts about the impact of the organisational changes on these opportunities. • The duration of handovers continued to result in breaches of working hour limits. 5.13 Learning from Deaths 2024-25 Quarter 3 and 4 Reports Jenny Milner was invited to present the Learning from Deaths Report, the content of which was noted. It was further noted that: • The Trust’s expected death rate remained lower than the national average, with the Trust ranked 12 out of 119. Page 6 • Further improvements in terms of the sharing of learning from Mortality and Morbidity meetings were required. Consideration was been given to using the Ulysses tool. • The Trust’s medical examiner service had reviewed more than 1,000 deaths since inception. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2024-25 Quarter 4 Review Martin de Sousa and Kelly Kent were invited to present the Corporate Objectives 2024/25 Quarter 4 Review, the content of which was noted. It was further noted that: • The Trust had delivered 50% of its annual objectives for 2024/25 and 37.5% of objectives had been partially achieved or had incurred minor delays. Two objectives remained ‘red’. • Particular areas to highlight included progress on long-waiters, patient experience, turnover/sickness of staff, and capital scheme delivery. The Trust had also been successful in slowing the rate by which the waiting list grew and in delivering Cost Improvement Programmes. • Areas of concern included the financial position, patients with no criteria to reside, and staff experience. • The Trust was in control of the delivery of some of the objectives, but full delivery of others was outside of the Trust’s control. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework (BAF) Update, the content of which was noted. It was further noted that: • The BAF had been previously reviewed by the Board in March 2025, following which it had been reviewed by the relevant executive directors and committees. • None of the ratings of the risks had been amended. However, the target dates for three risks had been extended to reflect the challenges in achieving the target rating. • The Trust was holding a higher overall level of risk than had previously been the case. It was considered important to ensure that risks were managed across domains and not in silos. • The Trust was using its risk appetite to support decision-making such as in capital prioritisation and in terms of the decisions required to deliver its 2025/26 plans. • A risk appetite review had been scheduled at a future Trust Board Study Session on the basis that the current situation potentially necessitated changes in terms of the Trust’s stated risk appetite. Action The review of risk appetite was to be scheduled to take place at the Trust Board Study Session on 3 June 2025. Page 7 6.3 South Central Regional Research Delivery Network (SC RRDN) 2024-25 Annual Performance Review and 2025-26 Annual Plan Paul Grundy and Clare Rook were invited to present the South Central Regional and Research Delivery Network (SC RRDN) 2024/25 Annual Performance Review and the SC RRDN 2025/26 Annual Plan, the content of which was noted. It was further noted that: • During the year the organisation transitioned from the Clinical Research Network Wessex to the South Central Regional Research Delivery Network, whereby the Wessex and Thames Valley and Midlands Clinical Research Networks were integrated into a single entity. • In the Wessex region, 33,000 participants were recruited to over 500 studies during the first half of the year. A further 35,000 participants were recruited to over 800 studies during the second half of the year in the South Central region. • Commercial research remained a priority, with the South Central region benchmarking well in terms of recruitment. • In terms of the 2025/26 plan, the NHS 10-year plan was awaited, as this would likely impact the plan. It was currently intended that the network would focus on the National Institute for Health Research’s seven priorities. A stakeholder group was being convened to inform the SC RRDN’s direction of travel. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governos’ (CoG) meeting 29 April 2025 The Chair presented a summary of the Council of Governors’ meeting held on 29 April 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • Annual Report and Quality Account Timetable 2024/25 • Draft Quality Account • Corporate Objectives • Non-NHS Activity • Governor Attendance at Council of Governor meetings • Council of Governors’ Elections 2025 • Appointment to the Governors’ Nomination Committee • Membership Engagement and Governor activity • Chair’s and Non-Executive Directors’ appraisal outcomes 7.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. It was further noted that, due to an issue with the electronic signature platform, a number of items were included in the report, which should have been included in previous reports. 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’. Page 8 8. Any other business Gail Byrne informed the Board that a joint targeted area inspection of the Trust’s Emergency Department and Maternity service by the Care Quality Commission (CQC), social services and the police was scheduled to take place on 20 May 2025, which would focus in particular on safeguarding of children. In addition, a routine Ionising Radiation (Medical Exposure) Regulations inspection was due to take place in June 2025. It was noted that the CQC had recently carried out unannounced inspections at Portsmouth Hospitals University NHS Trust and at South Central Ambulance Service NHS Foundation Trust. Accordingly, it appeared likely that the Trust should also expect an unannounced CQC visit, followed by a Well-Led review. It was noted that this was Dave Bennett’s last formal scheduled Board meeting, as his second three-year term was due to expire on 14 July 2025. The Board expressed its thanks to Dave Bennett. 9. Note the date of the next meeting: 15 July 2025 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Trust Board – Open Session 13/05/2025 - 5.6 Performance KPI Report for Month 12 1246. Virtual outpatients appointments Linning-Karp, Duncan 15/07/2025 Explanation action item Duncan Linning-Karp agreed to investigate why the number of virtual outpatients appointments had reduced. 1247. Friends and family test Byrne, Gail 15/07/2025 Explanation action item Gail Byrne agreed to examine the trend in respect of the friends and family test negative score for inpatients. Trust Board – Open Session 13/05/2025 - 6.2 Board Assurance Framework (BAF) Update 1248. Risk appetite Byrne, Gail 03/06/2025 Explanation action item The review of risk appetite was to be scheduled to take place at the Trust Board Study Session on 3 June 2025. Status Pending Pending Completed Page 1 of 1 Agenda Item 5.1 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Audit & Risk Committee Meeting Date: 9 June 2025 Key Messages: • • • • • The committee considered the results of a review of historical private activity (pre-2022/23) which had not been invoiced by the Trust. It was noted that, of the £2.5m total, £1.6m had since been paid, but that £0.9m should be written off. It was further noted that this issue should not arise in future due to changes in contracting arrangements and improvements in processes. The committee noted an update in respect of the Trust’s submission as part of the annual National Cost Collection exercise. The committee received a report on waivers of competitive tendering between October 2024 and March 2025, noting that these represented c.£11m of activity over the period. The committee reviewed a draft of the Annual Report and Accounts for 2024/25. The committee noted that the external audit had not progressed as planned. The committee received the Quarter 4 Fraud, Bribery and Corruption Work Plan Update Report, noting that under the Counter-Fraud Functional Return that the Trust was green-rated. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 6.3 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • There had been an increase in the number of critical risks recorded from 30-35 to c.50. Many of these risks related to staffing or capacity. • It was noted that some of this increase was driven by new risks being identified (or existing risks worsening), but that existing critical risks were not being closed due to insufficient resources. • In addition, following the Six Facet survey, there had been an improvement in the articulation of Estates-related risks, which was now reflected in the total number of operational risks. • The committee reviewed the Board Assurance Framework, noting that all risks had been reviewed by the relevant executive(s). 7.2 Review of Standing Assurance Rating: Risk Rating: Financial Instructions 2025-26 Substantial N/A • The committee reviewed the Trust’s Standing Financial Instructions, noting that changes were proposed to two areas: employee expenses and non-pay requisition limits. Any Other Matters: • The committee reviewed the Trust’s internal audit plan and agreed that a cyber security audit should be included as part of the plan. Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Finance and Investment Committee Meeting Date: 2 June 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee reviewed the Finance Report for Month 1. The Trust had reported a deficit of £4.4m in line with its plan whereby the Trust would move from a deficit to breakeven to surplus over the course of the year thereby achieving an overall breakeven position at year end. • The Trust’s underlying deficit was £7.2m in month. This was driven by patients having no criteria to reside, activity above block contract levels, and mental health patients. Use of bank staff had normalised when compared to Month 12, but there had been high drugs spend and lower than expected income which was under investigation. • The Trust was on track in terms of its Cost Improvement Programme (CIP). • The committee received an update in respect of the Trust’s cash position, noting that the Integrated Care Board had agreed to move scheduled payments to aid the Trust’s position. The Trust was forecasting a £7m negative balance in March 2026. • The committee reviewed the ‘Acute Drivers of Deficit’ report prepared by Deloitte, noting that many of the identified areas were long-term and/or structural issues. • The committee received an update on the Trust’s financial improvement programmes, noting that although c.£80m of the £110m CIP was currently viewed as ‘high risk’, this was expected to improve as schemes became more mature. • The committee noted the Trust’s response to a request to consider proposed workforce targets based on removing 50% of reported increases in corporate services expenditure since 2018/19. It was noted that the Trust expected to deliver this target through its existing plans. • The committee received an update in respect of the national and local contracting process, noting that most areas had now been agreed. The potential changes in Elective Recovery Funding posed a risk to the Trust. In addition, it was likely that £20-30m of activity would remain unfunded. N/A Any Other Matters: The committee received the Always Improving – Transformation End of Year Report, noting progress made. Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Finance and Investment Committee Meeting Date: 23 June 2025 Key Messages: • • • • • The committee reviewed the Finance Report for Month 2 (see below). The committee received an update in respect of the Trust’s cash position, noting that the position continued to deteriorate. It was further noted that discussions were underway with local providers, as some providers have cash whilst at the same time others risked running out. The committee received an update on the Urgent and Emergency Care Transformation Programme, noting that the Trust was targeting a reduction in length of stay by a further 5%. The committee noted an update from UHS Estates Limited and progress on a number of programmes. The committee considered a summary of the Spending Review presented by the Chancellor of the Exchequer on 11 June 2025. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 2 Assurance Rating: Risk Rating: Substantial High • The Trust had recorded an in-month deficit of £3.8m, which was in line with its plan to reach a breakeven position by year end. • The Trust had achieved its planned Cost Improvement Programme delivery level, although much of this was due to non-recurrent savings, which creates a challenge later in the year. • The Trust’s underlying deficit remained at £7.2m, consistent with Month 1. • Income had been lower than expected with reductions in income from pathology and the Channel Islands. Non-pay costs for drugs and clinical supplies also remained a challenge. • The committee reviewed the Trust’s workforce trajectory for 2025/26, noting that even if all ‘red’ CIP schemes were to deliver, this would still result in a shortfall. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). Any Other N/A Matters: Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.3 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: People and Organisational Development Committee Meeting Date: 25 June 2025 Key Messages: • The committee reviewed the People Report for Month 2 including progress on the Workforce Plan for 2025/26 (see below). • The committee noted that the plans for the Divisional restructure are now underway with the intention of implementing these on 01 July 2025. It is understood that whilst not all people plans have been finalised at a granular level, it is anticipated that most issues will be resolved through natural attrition and through the Mutually Agreed Resignation Scheme (MARS). • The MARS application window has now closed and there has been significant interest with 220+ applications submitted. These are currently being assessed for suitability and it is planned that the outcomes will be shared with applicants by 04 July 2025. Not all applications will be accepted as some posts cannot be surrendered, and the organisation cannot afford to accept them all. Whilst each resignation will represent a long-term saving there is a very real risk to in year cost pressures as all successful MARS applications will need to be funded locally, as there is no national funding to support this. • Additional recruitment controls also remain in place including a freeze on non-clinical recruitment, and a hold on 30% of clinical recruitment. • The committee noted that the scale of organisational change is significant and this is likely to be unsettling for staff. A number of support mechanisms have been implemented focussed on wellbeing, and this includes specific organisational change workshops targeted at leaders across the Trust to support them in supporting the wider workforce. The committee reflected that this is a positive step and that once the organisational restructure has completed, this should be used as a foundation for implementing change and leadership training as business as usual. • The committee received an update on the organisation’s education position and the current challenges and opportunities related to this. The committee acknowledged the significant risk to future workforce as a result of the current challenges across the NHS, in combination with the restricted and reduced funding streams which facilitate staff access to education and development. The committee noted the need to review education capacity again at UHS once the long-term workforce plan is published later in the year. Page 1 of 2 Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: 5.10 People Report for Month 12 Assurance Rating: Risk Rating: Substantial High • The Trust’s overall workforce grew by 19 WTE in May 2025 however it is still below the NHSE plan by 107 WTE. It was noted that turnover remains lower than average and it is suspected that this will be due to system wide recruitment controls limiting roles UHS staff may move into, in addition to a wider lack of opportunity in the jobs market as general employer confidence reduces. • Additionally, whilst both remain below plan, there has been an increase in temporary staffing bank and agency usage noting that April was a very low month. • The committee noted that the workforce plan is ambitious and sets out a reduction in headcount of c.750. All schemes to deliver this have been assessed for maturity and continue to be worked up, although even if it were to be assumed that all are followed through to completion, there is still a shortfall which needs to be addressed. Significant work has been undertaken to forward plan the trajectory. • It was noted that consideration had been given to the recruitment controls and whether these needed to be taken further, however as it will take several months to fully implement and see the benefit of those in place currently, this was decided against. The improvements in forecasting, and monthly review, will support this decision so that it can be reviewed again later in the year, probably September. • The committee discussed the need to track indicators related to people, money, performance and quality and consideration will be given to a balanced scorecard. • The committee received a further update in respect of the Band 2/3 pay dispute and in respect of the portering department. • The committee also received a series of updates on recent national letters to Trusts including a required review of job evaluation processes and analysis work on non-frontline nursing roles. Page 2 of 2 Agenda Item 5.4 Committee Chair’s Report to the Trust Board of Directors 15 July 2025 Committee: Quality Committee Meeting Date: 2 June 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • It was n
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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.
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Papers Trust Board - 13 January 2026

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

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Date Time Location Chair Apologies Agenda Trust Board – Open Session 30/01/2024 9:00 - 13:00 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd Diana Eccles 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient or staff story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Break 9:15 4 Minutes of Previous Meeting held on 30 November 2023 9:25 Approve the minutes of the previous meeting held on 30 November 2023 5 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. 6 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 6.1 Briefing from the Chair of the Audit and Risk Committee (Oral) 9:35 Keith Evans, Chair 6.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:40 Dave Bennett, Chair 6.3 Briefing from the Chair of the People and Organisational Development 9:45 Committee (Oral) Jane Harwood, Chair 6.4 Briefing from the Chair of the Quality Committee (Oral) 9:50 Tim Peachey, Chair 6.5 Chief Executive Officer's Report 9:55 Receive and note the report Sponsor: David French, Chief Executive Officer 6.6 Performance KPI Report for Month 9 10:25 Review and discuss the report Sponsor: David French, Chief Executive Officer 6.7 Finance Report for Month 9 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 6.8 People Report for Month 9 11:15 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 6.9 11:35 Break 6.10 Maternity Safety 2023-24 Quarter 3 Report 11:45 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Emma Northover, Director of Midwifery/Marie Cann, Maternity/Neonatal Safety Lead/Alison Millman, Safety & Quality Assurance Matron 7 STRATEGY and BUSINESS PLANNING 7.1 Corporate Objectives 2023-24 Quarter 3 Review 12:00 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendees: Martin De Sousa, Director of Strategy and Partnerships/Kelly Kent, Head of Strategy and Partnerships 7.2 Board Assurance Framework (BAF) Update 12:10 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 8 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 8.1 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 Page 2 8.2 Review of Standing Financial Instructions 2023-24 12:25 Review and approve the SFIs Sponsor: Ian Howard, Chief Financial Officer Attendee: Phil Bunting, Director of Operational Finance 8.3 Finance and Investment Committee Terms of Reference 12:30 Review and approve the Terms of Reference Sponsor: Dave Bennett, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 8.4 Quality Committee Terms of Reference 12:35 Review and approve the Terms of Reference Sponsors: Tim Peachey, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 9 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 10 Note the date of the next meeting: 28 March 2024 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 30/11/2023 9:00 – 13:00 Location Chair Present Microsoft Teams Jenni Douglas-Todd (JD-T) Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Duncan Linning-Karp, Deputy Chief Operating Officer (DL-K) (for J Teape) Ian Howard, Chief Financial Officer (IH) Femi Macaulay, Interim NED (FM) Tim Peachey, NED (TP) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) James Allen, Chief Pharmacist (JA) (item 5.12) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Julie Brooks, Head of Infection Prevention Unit (JB) (item 5.13) Marie Cann, Maternity/Neonatal Safety Lead (MC) (item 5.9) Rosemary Chable, Head of Nursing for Education, Practice and Staffing (RC) (item 5.15) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 5.11) Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian (CM) (item 5.15) John Mcgonigle, Emergency Planning & Resilience Manager (JM) (item 7.1) Alison Millman, Safety & Quality Assurance Matron (AM) (item 5.9) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.10) Emma Northover, Director of Midwifery (EN) (item 5.9) Danielle Sinclair, Deputy Emergency Planner (DS) (item 7.1) Julian Sutton, Interim Lead Infection Control Director (JS) (item 5.13) 1 member of the public (item 2) 5 governors (observing) 1 member of staff (observing) 5 members of the public (observing) Apologies Diana Eccles, NED (DE) Joe Teape, Chief Operating Officer (JT) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. Tim Peachey informed the Board that he now sits on the combined Portsmouth Hospitals University NHS Foundation Trust and Isle of Wight NHS Trust board, following the recent organisational changes. There were no further interests to declare in the business to be transacted at the meeting. Page 1 The Chair provided an overview of her activities since October 2023, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Patient Story Karol Muir was invited to speak about her experience as a patient when she was diagnosed with neck and tongue cancer in early 2021. It was noted that: • Ms Muir’s experience was mixed with some poor experiences when given the diagnosis and by a staff member lacking compassion when addressing her claustrophobia. • In other instances, Ms Muir received a good service such as when a mask was being made for her radiotherapy and her experience on the acute oncology ward. • The Board acknowledged that kindness and compassion was very important. • The Board also noted that it was important to hear both good and bad aspects of patients’ experiences to enable the Trust to improve its services. 3. Minutes of the Previous Meeting held on 28 September 2023 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 28 September 2023, subject to one minor amendment to item 5.2. 4. Matters Arising and Summary of Agreed Actions It was noted that all actions had either been completed or were not yet due. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to provide an overview of the meeting held on 27 November 2023. It was noted that: • The committee reviewed the Finance Report for Month 7 (item 5.5), much of which formed the basis of the Trust’s submission for the second half of 2023/24. • The committee examined the Trust’s capital re-prioritisation plans along with proposals for 2024/25 and 2025/26. • The Trust had identified £71.3m of Cost Improvement Programme schemes, which, when adjusted for risk, represented approximately £59m of savings. It was noted that the Trust was underweight in terms of recurrent savings. • The committee reviewed the Trust’s productivity on the basis of both the NHS methodology and a revised methodology, which took into account factors such as an appropriate rate of inflation. Under the NHS methodology, the NHS’s underperformance was 16% compared to 2019/20 and the Trust was 18% below that in 2019/20. However, under the revised model, the Trust was under-performing by only 6-7%. • The committee reviewed a proposal for an Integrated Care System-wide electronic patient record system. 5.2 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to provide an overview of the meeting held on 22 November 2023. It was noted that: • The committee reviewed the People Report for Month 7 (item 5.7). It was noted that the Trust’s substantive workforce continued to grow and whilst Page 2 agency use was under control, there had been an increase in use of bank staff, particularly due to demands in the Emergency Department, mental health nursing and staffing of surge areas. • It was noted that self-reporting of disabilities by staff and the rate of appraisals had both declined. • The initial indication in terms of the response rate to the staff survey showed a lower response rate than in previous years. 5.3 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 27 November 2023. It was noted that: • The committee reviewed the Trust’s quality indicators and noted that the rate of falls and infections gave rise to concerns about the application of fundamentals of care principles. It was considered possible that the different focus during Covid-19 was a possible contributory factor. • The Trust had reported an increase in the number of complaints, although much of this increase was due to a change in the criteria of what was deemed to be a complaint. • The committee reviewed the results of the Experience of Care survey. Although the national picture had worsened, the Trust’s position remained essentially as before. • The Trust’s approach to end-of-life care was generally very good, although consideration needed to be given to the delivery of mandatory training to all staff. • In view of the general election due to take place before the end of 2024, it was considered likely that the Trust would receive an increased number of Freedom of Information Act requests. 5.4 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The Chancellor of the Exchequer had delivered his autumn statement on 22 November 2023, and although there were no specific announcements concerning the health and care sector, there was an expectation of increased public sector productivity. It was noted that the Government had previously announced £800m of additional winter funding for the NHS, although this was mostly repurposed existing funding. • A proposed pay settlement for senior doctors was expected to be voted on by British Medical Association members. • The Care Quality Commission had commenced a roll out of its new single assessment framework in the South region. • The public hearings for module 2 of the UK Covid-19 Inquiry had commenced on 3 October 2023. • The Trust had identified 181 cases of lung cancer through the Targeted Lung Health Check Programme. The financial impact of this programme was difficult to quantify, as it had led to a higher surgical workload, but reduced need for chemo- and radiotherapy. Other conditions had also been discovered through the screening programme. 5.5 Performance KPI Report for Month 7 Duncan Linning-Karp was invited to present the Performance KPI Report for Month 7, the content of which was noted. It was further noted that: • In terms of benchmarking against other trusts, the Trust was in the top quartile in all areas except one. Page 3 • There had been 23 breaches of the target for long-waiters. • The Trust was facing challenges in meeting the 31-day cancer treatment target due to increases in demand for radiotherapy and demand for prostate cancer treatment. The Board noted the spotlight on the Emergency Department. It was further noted that: • There had been a 17% increase in demand since 2019/20. • The Trust was targeting 76% of type 1 patients being seen within four hours, but this would be challenging and dependent on the General Practitioners (GPs) working at the Emergency Department and on a reduction in the number of patients with no criteria to reside. • The Trust was reviewing its processes to free up space and provide options to bypass the Emergency Department when individuals were referred by their GP. In addition, admission and discharge processes were also being reviewed. • It was noted that the GP ‘village’ in the Emergency Department would be insufficient on its own to reach the 76% target. • The biggest constraints in terms of performance were the speed of decisionmaking and the availability of beds. 5.6 Finance Report for Month 7 Ian Howard was invited to present the Finance Report for Month 7, the content of which was noted. It was further noted that: • The Trust had submitted to the Integrated Care Board its plans for the second half of the financial year, which anticipated a revised end-of-year deficit of £31.5m. • The Trust had a year-to-date deficit of £25m, although this was prior to receipt of anticipated additional funding for the costs of industrial action. • The Trust was consistently delivering above the ceilings agreed for services under ‘block’ contracts, which meant that the additional activity was unfunded. • The Trust’s Elective Recovery performance remained good, and the resultant funding received was £4.5m above the Trust’s plan. 5.7 People Report for Month 7 Steve Harris was invited to present the People Report for Month 7, the content of which was noted. It was further noted that: • The workforce grew by 93 whole-time equivalents during the month, and the total workforce was 270 over the plan submitted to NHS England. This increase was driven in particular by newly qualified nurses still within the supernumerary period, increased temporary staffing and a small increase in sickness absence. • Participation in the NHS staff survey was lower than that in previous years at around 40% compared to 55% during 2022/23. • Turnover and sickness rates remained lower than the Trust’s target levels. • There continued to be a high demand for mental health nursing staff, and it seemed likely that a system approach would be necessary to address this issue. 5.8 Break Page 4 5.9 Midwifery, Neonatal and Obstetric Anaesthetic Workforce Report Emma Northover, Marie Cann and Tim Peachey were invited to present the Midwifery, Neonatal and Obstetric Anaesthetic Workforce Report, the content of which was noted. It was further noted that: • Oversight of the midwifery, neonatal and obstetric workforce was a requirement of the NHS Resolution Maternity Incentive Scheme. It was noted that the obstetric element of the report would be provided at the next Board meeting on 19 December 2023. • The workforce faced a number of challenges, particularly in terms of recruiting to specialisms where there was a national shortage, and that activity in the service was unpredictable. • The Trust had in place a number of strategies to recruit staff and was also focusing on growing its own workforce in terms of skills where these were unobtainable in the market. • There were staff shortages in both maternity and neonatal teams. The maternity team was on a trajectory to fill its current vacancies and the shortages in the neonatal team were to be addressed through upskilling the Trust’s own workforce. • There had been a significant increase in the number of elective caesarean births, possibly driven by reduced confidence on the part of the public in maternity services due to recent media stories. • Due to the nature of the Trust’s services, it received a high number of high-risk patients, which placed further demands on its capacity. 5.10 Learning from Deaths 2023-24 Quarter 2 Report Jenny Milner was invited to present the Learning from Deaths Report for Quarter 2, the content of which was noted. It was further noted that: • In-patient deaths had fallen by 10% compared to the previous year, with deaths below the national average. • Five cases had been referred to internal morbidity and mortality meetings. • The Medical Examiner’s Office and Bereavement teams had been moved into the same structure in order to reduce administration and to also reduce the number of calls to families. 5.11 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • The Trust had been fined for the first time since 2016 due to seven breaches of the maximum 13-hour shift length. There was considered to be a possible issue with the handover process, which resulted in the breaches of shift duration. • Suggestions had been sought from staff in order to improve the Trust’s processes. Page 5 5.12 Medicines Management Annual Report 2022-23 James Allen was invited to present the Medicines Management Annual Report for 2022/23, the content of which was noted. It was further noted that: • Over the course of the year, the Trust had improved its resilience in areas such as oncology pharmacy and had an increased focus on research. In addition, the aseptic site programme at Adanac Park was progressing. • The Trust was facing challenges in terms of its IT infrastructure and in filling clinical trials. • The next area of focus was to be on the storage of medicines. • There had been flooding in radio-pharmacology, but there had been minimal impact due to interventions undertaken and use of mutual aid. 5.13 Infection Prevention and Control 2023-24 Quarter 2 Report Julian Sutton and Julie Brooks were invited to present the Infection Prevention and Control Report for Quarter 2, the content of which was noted. It was further noted that: • The Trust continued to not meet the national standards for E-coli and C-Diff, although it compared reasonably well with comparator organisations. • Rapid gastro-intestinal testing continued to be of significant benefit in preventing norovirus outbreaks. • Respiratory testing time had increased, and the amount of time required for a person to be deemed a Covid-19 contact had been increased. • Approximately 50 patients had been impacted by a candida auris outbreak since March 2023. It was proving difficult to eradicate the source of the infections, and there was little understanding globally as yet of the pathogen. • The importance of adhering to fundamentals of care principles was emphasised, as there had been a number of preventable incidents due to poor hygiene practices. • The Hampshire and Isle of Wight Integrated Care Board was focusing on overprescribing of antibiotics, particularly by GPs. 5.14 Annual Ward Staffing Nursing Establishment Review 2023 Rosemary Chable and Gail Byrne were invited to present the Annual Ward Staffing Nursing Establishment Review 2023, the content of which was noted. It was further noted that: • It was a requirement for the Board to undertake a systematic ward staffing establishment review. • The Trust’s staffing levels were generally in line with expectations and staffing numbers have improved due to the Trust’s success in recruiting new staff. However, the influx of new, less experienced members of staff was placing pressure on more senior members of staff. When challenged on how staffing requirements were determined, it was noted that this assessment was based on analysis of data from multiple sources along with professional judgement. Page 6 5.15 Freedom to Speak Up Report Christine Mbabazi was invited to present the Freedom to Speak Up Report, the content of which was noted. It was further noted that: • Eighty-one cases had been raised in 2023/24. • Consideration was being given to publishing lessons learned from some of the Freedom to Speak Up cases on the staff intranet. • Additional support to line managers was also being examined such that staff were comfortable in approaching their managers, rather than utilising the Freedom to Speak Up process. • Some groups, such as junior doctors and some ethnic minorities, were generally less likely to engage with the Freedom to Speak Up process. • The Trust was recruiting more Freedom to Speak Up champions, especially from less engaged groups of staff. 6. STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update The Board Assurance Framework Update was noted. It was further noted that the Board Assurance Framework was due to be discussed in detail at the Trust Board Study Session scheduled to take place on 19 December 2023. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Duncan Linning-Karp and John Mcgonigle were invited to present the paper, ‘Emergency Preparedness, Resilience and Response Delivery Group (EPRR-DG) – Assurance Report’, the content of which was noted. It was further noted that: • The Trust’s preparedness had been assessed within ten domains, covering 62 core standards and multiple performance indicators within each. • The Trust was fully compliant with 60 of the 62 standards and was therefore ‘substantially compliant’. • The main area for improvement was in preparedness for a mass evacuation of the hospital. The Trust was working through a scenario for a full evacuation. • The Trust was also non-compliant in the area of a mass casualty scenario, as there had been new guidance released in this area. Work was ongoing to align with this new guidance. • Training in incident management had been delivered to senior leaders. 8. Any other business There was no other business. 9. Note the date of the next meeting: 30 January 2024 10. Items Circulated to the Board for reading The item circulated to the Board for reading was noted. Page 7 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 8 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 28/09/2023 6.2 Health and Safety Annual Report 2022-23 1041. Violence and aggression update Byrne, Gail Harris, Steve Machell, Craig 29/02/2024 Pending Explanation action item Gail Byrne, Steve Harris and Craig Machell agreed to schedule a further update in respect of violence and aggression at a future Trust Board Study Session. Page 1 of 1 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose: Issue to be addressed: Response to the issue: Chief Executive Officer’s Report 6.5 David French, Chief Executive Officer 30 January 2024 Assurance Approval or reassurance Ratification Information X My report this month covers updates on the following items: • Operational Update • National Audit Office qualification of DHSC accounts • External Recruitment Status • South Hampshire College Group • DHSC Consultation on New Nursing Spine Pay Points • NHS Providers Governance Survey 2023 • Intensive Care Society’s 2023 National Awards 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 5 Operational Update January 2024 has been a very challenging month operationally for everyone within the Trust. Having safely navigated the period of industrial action by doctors in training between the 2nd and 8th January 2024, the Trust has experienced a period of heightened operational pressures which has seen record levels of patients within the hospital without criteria to reside (medically fit). These reached record levels on one day of 270 (over 25% of adult inpatient general acute bed base) coupled with significant infection outbreaks resulting in further wards closed (three at the time of writing) and closure of 23 bays across the wards. This in turn has caused a significant backlog of patients within the emergency department and has also sadly resulted in a significant increase in ambulance handover delays and queues within the adult emergency department footprint. The Trust has continued to manage these pressures as best as it can through hospital incident management arrangements and significant oversight of available beds and discharges daily. Unfortunately, the Trust has also had to cancel some elective operations due to lack of available beds despite all surge bed areas in the hospital being fully open. The Chief Nursing Officer has also implemented a number of enhanced infection prevention measures including wearing surgical masks in adult clinical areas and has also introduced temporary visitor restrictions to further limit the risk of spreading infection. Looking forward, the Trust continues to do all it can to respond to the current challenges and has invited the Emergency Care Intensive Support Team from NHS England to review its processes via an invited visit during January 2024. The Trust is also currently reframing its flow programme to focus on operational oversight. In addition, the Trust is rigorously eliminating all discharge delays within its control as well as continuing to work with community partners across health and social care to try and deal with the longer-term issues of capacity outside of the hospital. According to ‘Winter Watch’ published by NHS Providers, an overview of the situation in NHS England, during the week commencing 8 January 2024: • 93.3% of general and acute beds were occupied and 586 beds were closed due to diarrhoea and vomiting and norovirus. • A total of 90,294 patients arrived by ambulance, an increase of 25% compared to the previous year. • There was an average of 23,645 patients each day who no longer met the criteria to reside. Of these, over half (57.7%) remained in hospital. • An average of 49,039 staff were absent each day. National Audit Office qualification of DHSC accounts The NAO has qualified DHSC accounts for financial year 2022/23 due to the way in which the elective recovery fund (ERF) was administered. The Government established the ERF in 2022/23 to incentivise trusts to increase their activity after Covid-19. The money was paid to trusts and ICBs on the assumption targets would be met, but there were intended to be financial penalties if the activity goal (104% of 2019/20 baseline) was not met. However, the clawback mechanism was suspended over fears this would destabilise local systems, most of which were underperforming on their elective targets. As a result, local organisations were allowed to keep the funding, regardless of the number of patients they treated. Page 2 of 5 In their audit statement, NAO state “ERF was required to be ‘earned’ by integrated care systems hitting elective recovery targets. Where elective recovery targets were not met, the cash received by the department should have been returned to the consolidated fund.” NHSE’s 2022/23 accounts state: “The lower levels of elective activity were due to ongoing Covid19 pressures and longer lengths of stay, factors for which no additional funding had been provided. Therefore, we decided to allow providers to retain the elective funding to cover these costs, which the government has now deemed to be irregular.” UHS was one of only a handful of providers which achieved the ERF target of 104%; UHS achieved 108% whereas the average performance for the country was 97%. Of course, like all providers, UHS incurred the costs described in the NHS accounts for Covid-19 pressures and longer lengths of stay for which the ERF money was used to cover, but also incurred the costs of delivering additional elective activity which others did not. No income was received to cover the UHS cost of activity between 104% and the national average of 97%, whereas other providers were able to keep the money originally intended to fund the 104% target. We estimate the UHS cost of this 7% additional activity to be around £10m. The £10m cost of this activity has subsequently been ‘baked’ into the UHS baseline and is therefore a significant contributor to UHS’s current financial challenge and a strong headwind affecting the Trust’s ability to return to financial break-even. External Recruitment Status The Board is aware that following an update to the Trust’s forecasted headcount for 31 March 2024, additional recruitment controls were introduced on 22 December 2023 which remain in place. The executive team has been working through the detail of how the controls operate effectively but also with due regard to clinical quality and safety. One of the major challenges has been the dissonance between how it feels on the ground (busier than ever) and the explicit financial direction received from the Centre. This has been a fast-moving and dynamic situation and we will update the Board during the Board meeting on how we are navigating that challenge and how we are ensuring that clinical safety and quality is protected. South Hampshire College Group During January 2024, the Chief People Officer and Head of Education met the senior leadership team from the newly formed South Hampshire College Group (SHCG). This new organisation is the result of a merger between Eastleigh, Southampton City, and Fareham colleges, bringing together over 3,000 students across the area. The Trust will be working to create an overarching partnership with the group focused on growing vocational and entry-level opportunities for students into roles at the Trust (health-related, estates, business administration and digital). This supports the Trust’s People Strategy objectives of extending the diversity of our relationships with education providers to support a wider range of education to employment opportunities. It also supports the ambitions of the NHS long-term workforce plan, particularly around apprenticeship opportunities for non-graduate entry roles. SHCG can play an important role in the career promotion of the Trust, including working in partnership on industry placements. Senior leads from SHCG and the Trust will be meeting again in the Spring to take these activities forward. Department of Health and Social Care Consultation on New Nursing Spine Pay Points In May 2023, the government agreed a deal for the Agenda for Change (AfC) workforce through the NHS Staff Council. During negotiations, concerns were raised about how the AfC pay structure is affecting the career progression and professional development of nurses, and the direct impact that this is having on recruitment and retention. The Royal College of Nursing (RCN) Page 3 of 5 suggested that a separate pay spine for nursing staff could address these concerns. At present the same pay scales are used for all roles covered by Agenda for Change with banding (pay grade) determined through job evaluation. This call for evidence is being published to explore these specific concerns, to understand the benefits and challenges of a separate nursing pay spine, and to explore other potential approaches to addressing any issues identified. This exploration does not form part of the AfC deal that was agreed with the NHS Staff Council. The consultation is public and can be responded to as an individual (within or outside healthcare) or as an NHS organisation. The Trust will be participating in the consultation through evidence sessions being organised by NHS Employers and through its own written response. NHS Providers Governance Survey 2023 In September and October 2023, NHS Providers invited chairs, company secretaries and other corporate governance leads in NHS trusts and foundation trusts to complete a survey in relation to boards, their assurance committees and how trusts are developing in relation to the systems they are part of. The results of the survey were published on 15 December 2023. In summary: • 86% of respondents agreed or strongly agreed that the board has time to focus on key risks and issues, but the comments provided gave a clear sense that it can be challenging to prioritise and effectively cover everything. • Almost all respondents (99%) agreed or strongly agreed that the way the committees report to the board can provide it with assurance. • However, many respondents stated that space on agendas is under pressure, often attributing this to initiatives from the centre as well as new system and partnership-working related matters. This contributes to reduced bandwith for those producing and seeking to digest reporting and assurance information and putting pressure on the time available for effective discussion and scrutiny. • The pressures on executive directors were highlighted and there were concerns about too much detail coming through to boards and committees. • More than half of respondents (58%) said that their trust has associate non-executive directors, with the most common reason being developmental and to aid succession-planning. • Trusts’ experience in systems remains variable and whilst there has been some improvement, for the most part, the picture remains one of considerable variation. Of 36 comments in relation to this subject, 23 were critical of the way systems are working at present and a further eight said it was too soon to say. • Improvements were reported in relation to trust boards’ ability to influence the development of the systems they are part of, and in non-executive directors’ perceived confidence about their role and responsibilities in systems. • Only 20% of respondents expressed confidence about approaches to continuous improvement across systems and the lowest level of confidence was reported for how risk was managed across systems (12%, compared to 20% in the prior year). • 42% of respondents have a board member who is also a trust partner member on an Integrated Care Board, and chairs and governance leads were positive about the influence and access they felt having a board member in this role gave them. The full report can be read at: https://nhsproviders.org/resources/surveys/governance-surveyresults-2023 Page 4 of 5 Intensive Care Society’s 2023 National Awards The neuro-physiotherapy team, who work closely with the Trust’s Neuro Intensive Care Unit, were awarded ‘Team of the Year’ at the Intensive Care Society’s national awards. Footage of the award ceremony can be viewed at: https://www.youtube.com/watch?v=fHPem9G_JGo (watch from 9 minutes 35 seconds in). I would like to congratulate the team on this achievement. Page 5 of 5 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author Date: Purpose Performance KPI Report 2023-24 Month 9 6.6 David French, Chief Executive Officer Sam Dale, Associate Director of Data and Analytics 30 January 2024 Assurance or Approval reassurance Y Ratification Information Issue to be addressed: The report aims to provide assurance: • Regarding the successful implementation of our strategy • That the care we provide is safe, caring, effective, responsive, and well led Response to the issue: The Performance KPI Report reflects the current operating environment and is aligned with our strategy. Implications: This report covers a broad range of trust performance metrics. It is (Clinical, intended to assist the Board in assuring that the Trust meets Organisational, regulatory requirements and corporate objectives. Governance, Legal?) Risks: (Top 3) of carrying out the change / or not: This report is provided for the purpose of assurance. Summary: Conclusion and/or recommendation This report is provided for the purpose of assurance. Page 1 of 29 Report to Trust Board in January 2023 Performance KPI Board Report Covering up to December 2023 Sponsor – David French, Chief Executive Officer Author – Sam Dale, Associate Director of Data and Analytics Page 2 of 29 Report to Trust Board in January 2023 Report guide Chart type Example Cumulative Column Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart Variance from Target Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). The line shows our performance, and the bar underneath represents the range of performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts is used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. Page 3 of 29 Report to Trust Board in January 2023 Introduction The Performance KPI Report is presented to the Trust Board each month to provide assurance: • regarding the successful implementation of our strategy; and • that the care we provide is safe, caring, effective, responsive, and well led. The content of the report includes the following: • The ‘Spotlight’ section, to enable more detailed consideration of any topics that are of particular interest or concern. The selection of topics is informed by a rolling schedule, performance concerns, and requests from the Board. • An ‘NHS Constitution Standards’ section, summarising the standards and performance in relation to service waiting times; and • An ‘Appendix,’ with indicators presented monthly, aligned with the five themes within our strategy. Due to the earlier timing of the December 2023 Board, at the time of publishing last months’ report several of the validated IPR data points were not yet available but have now been updated within this report. • 31 - Patients on an open 18 week pathway (within 18 weeks) • 33 - Patients on an open 18 week pathway (within 52 weeks) • 34 - Patients on an open 18 week pathway (within 65 weeks) • 35 - Patients on an open 18 week pathway (within 78 weeks) • 35a - Patients on an open 18 week pathway (within 104 weeks) • 32 - Total number of patients on a waiting list (18 week referral to treatment pathway) • 36 - Patients waiting for diagnostics • 37 - % of patients waiting over 6 weeks for diagnostics Other changes of note within the report include: • 7 –MRSA bacteraemia: A correction in the November 2023 data, which was reported as 1 case, but on review has been changed to 2 cases. • 13 – Serious Incidents Requiring Investigation: As part of the move to the new Patient Safety Incident Response Framework (PSIRF) from October 2023, the metrics have removed the reporting of SIRIs, although Patient Safety Incident Investigations (PSII) are still being reported in this measure. • 38 – Cancer 2 Week Wait: In December 2023 NHS England stopped publishing 2 week wait data. Benchmark data is available for the period up until October 2023 for other hospitals. UHS will continue to publish our own performance against this metric. • 41 / 42 – Cancer 31 Day Performance / Cancer 31 Day Subsequent Treatment performance: From December 2023, NHS England measurement methodology changed, and published data from October 2023 onwards for 31 Day Cancer Performance combines both First and Subse quent treatment performance. As a result, metric 42 (Cancer 31 Day Subsequent Treatment) has been removed. Page 4 of 29 Report to Trust Board in January 2023 Summary This month’s spotlight covers Cancer performance. It highlights how UHS has seen improving levels of performance against the three new national cancer metrics, and the interventions that have been made to improve performance despite the ongoing challenges of increased demand. Detail is also provided by tumour site, outlining the specific challenges and actions taken by Care Groups to address performance. Areas of note in the appendix of performance metrics include: 1. As outlined within the Cancer spotlight, our increased focus on Cancer performance has led to significant improvements in 2 Week Wait performance (increasing to 88.9% in November 2023), UHS being in the top three teaching hospitals for 62 Day performance, and being the top teaching hospital for 28 Day Faster Diagnosis for the last three months – with an improvement in performance to 85.4%. 2. The Emergency Department (ED) four hour performance saw a small improvement in performance in December 2023 to 58.0%, although this remains below our H2 recovery ambitions. The GP programme has also led to some diversions away from the department which might otherwise have further improved performance. However, ED performance continues as a national issue, as illustrated by UHS remaining within the top quartile of teaching hospitals. 3. We have seen a further increase in the number of patients not meeting the Criteria to Reside in hospital which remains extremely high at an average of 203 patients through December 2023 – even though we would normally see a reduction over the Christmas period. 4. A positive ongoing reduction in the proportion of patients being readmitted within 28 days of discharge continues, with this standing at 10.6%. 5. There was a second consecutive month in the reduction of the waiting list to just over 58,000 patients. However, this remains significantly higher than pre-COVID, and there is often a softening of demand over the Christmas period. 6. We have also seen a continued reduction in the Diagnostic waiting list, which now stands at under 8,000 patients. The size of this waiting list is now broadly in line with pre-COVID levels, although the proportion of patients breaching the six week diagnostic standard is still higher. Ambulance response time performance The latest unvalidated weekly data is provided by the South Coast Ambulance Service (SCAS). Due to the significant challenges within the ED department, and the wider challenge with flow experienced in the trust since the New Year, we have seen an increase in handover times. In the week commencing 15 January 2024, our average handover time was 22 minutes 38 seconds across 675 emergency handovers, and 32 minutes 26 seconds across 35 urgent handovers. There were 73 handovers over 30 minutes, and 44 handovers taking over 60 minutes within the unvalidated data. Page 5 of 29 Report to Trust Board in January 2023 Spotlight Spotlight: Cancer performance 1. Introduction Cancer is a large basket of disparate diseases across every organ and tissue type of the body, unified by its biology in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread (metastasise) to other parts of the body. These cancerous diseases have very different treatments and prognoses. The other uniting factor underlying this name is that for many patients the word cancer generates significant anxiety and fear and recognising this, UHS works hard to provide the most streamlined service that we can offer to patients referred to our service. UHS is one of 12 regional cancer centres in the UK offering treatment for rare and complex cancers as well as children's cancer and brain cancer. We offer a wide range of treatments including novel therapies. UHS has historically benchmarked in the upper quartile, relative to our teaching hospital peers. We continue to perform well against the 28 day faster diagnosis and 62 day standards, but face challenges in meeting the 31 day standard. Recovery plans are in place focusing on the three key areas affecting this standard, radiotherapy, prostate surgery and skin (plastics). More d etail follows below. We continue to monitor cancer performance through regular performance meetings. However, there is an ongoing risk, with many tumour sites dependant on relatively few individuals to deliver, meaning that unexpected or unplanned absences can quickly affect performance. 2. Changes to Cancer Waiting Time Standards (CWT) In August 2023, NHS England received government approval to implement changes to the cancer waiting times standards from 1 October 2023. These changes were the outcome of a long term consultation which had the full support of NHS staff, patient groups and cancer. The proposed standards are in line with recommendations made by the Independent Cancer Taskforce in 2015 and the subsequent clinical review which was started in 2018. The three new standards (detailed below) are aligned to the requirements of modern cancer care, with a greater focus on outcomes and ensuring equitable access to care. The new treatment standards will measure waiting time for all patients regardless of their route into the system, rather than just those who were urgently referred by their GP. 1. The 28-day faster diagnosis standard (FDS). Patients with suspected cancer who are referred for urgent cancer checks from a GP, screening programme or other route should be diagnosed or have cancer ruled out within 28 days 2. A 62-day referral to treatment standard. Patients who have been referred for suspected cancer via any route and go on to receive a diagnosis should start treatment within 62 days of their referral. Page 6 of 29 Report to Trust Board in January 2023 Spotlight 3. A 31-day decision to treat to treatment standard. Patients, regardless of how they came to be diagnosed with cancer, should receive their treatment within a month of a decision to treat their cancer. These changes will still set the same high-performance bar for the same groups of patients as were covered by the previous standards and will increase the number and proportion of patients covered by the standards. They are designed to focus on two clear goals: achieving the fastest possible diagnosis, and for those who are diagnosed and require treatment, ensuring they receive treatment as quickly as possible. The new standards will also put all patients on a level playing field, regardless of the origin of their referral. Trusts do not need to make significant changes in terms of their data submissions – the only change of note in terms of overall process will be their reporting of performance against the 62-day standard to include patients who’ve entered cancer pathways via screening or consultant upgrades as well as those who were referred by their GP. In this paper, we explore early performance against the national targets in place for each of the new standards, UHS position compared to comparator Trusts and an exploration of the drivers and actions in place to improve performance for key tumour sites. 3. Cancer Referral Volumes At the start of the 2023 calendar year, the Trust experienced a 3000 period of significant volatility on cancer referrals which reached a five year high when 2,524 referrals were received in June 2023. 2500 2000 This high volume of referrals has remained since, but with some stabilisation of the monthly variance seen in the first half of the 1500 year. As expected, the festive period sees a reduction with 1000 December 2023 at 1,774. Despite this levelling off in recent 500 months, the referral volumes in 2023 averaged at 2,213 per month which overall is 7% higher than 2022 and 21% higher than 0 the 2021 calendar year. Ja n-22 Fe b -22 Ma r-22 Apr-22 Ma y-22 Jun-22 Jul -22 Aug-22 Se p -22 Oct-22 Nov-22 D e c-22 Ja n-23 Fe b -23 Ma r-23 Apr-23 Ma y-23 Jun-23 Jul -23 Aug-23 Se p -23 Oct-23 Nov-23 D e c-23 2022 2023 Graph 1: Cancer referral volumes by month Page 7 of 29 Report to Trust Board in January 2023 Spotlight 3,000 2,500 2,000 1,500 1,000 500 0 Jan Feb Mar Apr May Jun Jul Au g Sep Oct Nov Dec 2020 2021 2022 2023 Graph 2: Cancer Referrals – historic monthly comparison 4. Overall cancer waiting list (PTL) and patients waiting over 62 days (backlog) The overall waiting list size is heavily dependent on the number of two week wait referrals and the speed of seeing these patients, as the large majority of patients will leave the cancer waiting list at the point of being told that they don’t have cancer. Throughout
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Sex assignment in newborn babies - patient information

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This factsheet explains what sex assignment is and what happens when a baby's sex cannot be assigned as soon as they are born.
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/Media/UHS-website-2019/Patientinformation/Childhealth/Sex-assignment-in-newborn-babies-3505-PIL.pdf

NIHR BioResource

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Auto Generated Title The National Institute for Health Research (NIHR) BioResource was established to further clinical research within the UK by assisting researchers with volunteer recruitment, specifically volunteer recruitment by genotype and/or phenotype . Researchers can apply to the NIHR BioResource if they are interested in recalling volunteers from the panel. The unique benefit of the NIHR BioResource is that researchers are able to select volunteers for studies based on their genetic make-up or on other characteristics, such as markers in their blood cells. All of us have slight variations in our genes and these determine traits such as eye colour, skin colour, hair growth and height. It is also combinations of these variations that can predispose or protect an individual to certain diseases. Please visit NIHR BioResource website for more information. Alternatively, you can follow links below: Application process Cost BioResearch publications
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/ClinicalResearchinSouthampton/For-researchers/NIHR-BioResource/NIHR-BioResource.aspx

Papers Trust Board - 29 November 2022

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Date Time Location Chair Agenda Trust Board – Open Session 29/11/2022 9:00 - 13:20 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Staff Story The staff story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 29 September 2022 9:20 Approve the minutes of the previous meeting held on 29 September 2022 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Charitable Funds Committee (Oral) 9:30 Dave Bennett, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:35 Jane Bailey, Chair 5.3 Briefing from the Chair of the Quality Committee (Oral) 9:40 Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:45 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Integrated Performance Report for Month 7 10:05 Review and discuss the Trust's performance as reported in the Integrated Performance Report. Sponsor: David French, Chief Executive Officer 5.6 Finance Report for Month 7 10:35 Review and discuss the finance report Sponsor: Ian Howard, Chief Financial Officer 5.7 People Report for Month 7 10:45 Review and discuss the people report Sponsor: Steve Harris, Chief People Officer 6 Break 10:55 7 Infection Prevention and Control 2022-23 Q2 Report 11:05 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Interim Lead Infection Control Director/Julie Brooks, Head of Infection Prevention Unit 8 Medicines Management Annual Report 2021-22 11:15 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist 9 Equality, Diversity and Inclusivity (EDI) Update including Workforce Race 11:25 Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) Results 2022 Receive and discuss the reports Sponsor: Steve Harris, Chief People Officer Attendee: Ceri Connor, Director of OD and Inclusion 10 Annual Ward Staffing Nursing Establishment Review 11:35 Discuss and approve the review Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Rosemary Chable, Head of Nursing for Education, Practice and Staffing 11 Guardian of Safe Working Hours Quarterly Report 11:45 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 12 Learning from Deaths 2022/23 Quarter 2 Report 11:55 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Ellis Banfield, Associate Director of Patient Experience 13 Freedom to Speak Up Report 12:05 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian Page 2 14 Annual Assurance Process and Self-assessment against the NHS 12:15 England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Joe Teape, Chief Operating Officer Attendee: John Mcgonigle, Emergency Planning & Resilience Manager 15 STRATEGY and BUSINESS PLANNING 15.1 Board Assurance Framework (BAF) Update 12:25 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 16 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 16.1 Register of Seals and Chair's Actions Report 12:35 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 16.2 Review of Standing Financial Instructions 2022-23 12:40 Review and approve the SFIs Sponsor: Ian Howard, Chief Financial Officer Attendee: Phil Bunting, Director of Operational Finance 16.3 Corporate Governance Update 12:50 Receive and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 17 Any other business 13:00 Raise any relevant or urgent matters that are not on the agenda 18 Note the date of the next meeting: 31 January 2023 19 Items circulated to the Board for reading 19.1 CRN: Wessex 2022-23 Q2 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer Page 3 20 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 21 Follow-up discussion with governors 13:05 Page 4 3 Minutes of Previous Meeting held on 29 September 2022 1 Draft Minutes TB 29 Sept 22 OS v2 Minutes Trust Board – Open Session Date Time Location Chair Present 29/09/2022 9:00 – 13:00 Microsoft Teams Jenni Douglas-Todd (JD-T) Jane Bailey (JB), Non-Executive Director (NED) Gail Byrne (GB), Chief Nursing Officer Cyrus Cooper (CC), NED (from item 5.4 part two) Jenni Douglas-Todd (JD-T), Chair Keith Evans (KE), NED David French (DAF), Chief Executive Officer Paul Grundy (PG), Chief Medical Officer Steve Harris (SH), Chief People Officer Jane Harwood (JH), NED Ian Howard (IH), Chief Financial Officer Tim Peachey (TP), NED Joe Teape (JT), Chief Operating Officer In attendance Jane Fisher, Head of Health and Safety Services (JF) (for item 7.3) Sarah Herbert, Deputy Chief Nursing Officer (SHe) (for item 5.7) Femi Macaulay (FM), Associate NED Corinne Miller, Named Nurse for Safeguarding Adults (CM) (for item 5.8) Karen McGarthy, Named Nurse for Safeguarding Children (KMcG) (for item 5.8) Christine McGrath (CMcG), Director of Strategy and Partnerships Helen Potton, Associate Director of Corporate Affairs and Company Secretary (Interim) (HP) Helen Ralph, Manager, Transformation Team (HR) (for item 6.1) Annabel Shawcroft, Clinical Programme Officer, Transformation Team (AS) (for item 6.1) Jason Teoh, Director of Data and Analytics (JTe) (for item 5.11) Diana Ward, Clinical Outcomes Manager (DW) (for item 5.10) One member of the public (observing) 3 governors (observing) 5 members of staff (observing) 1 members of the public (observing) Apologies Dave Bennett (DB), NED 1. Chair’s Welcome, Apologies and Declarations of Interest JD-T welcomed all those attending the meeting which was being held by Microsoft Teams. Apologies were received from DB. CC would be joining the meeting later. 2. Patient Story HP introduced the Patient Story which focused on the experience of a mother and daughter who had used the Trust’s services. Mum advised that during the pandemic, her daughter had been diagnosed with cancer in her abdomen at the age of nine years old. Page 1 Her daughter had surgery followed by nine rounds of chemotherapy at the Trust followed by radiotherapy in London. Whilst on maintenance chemotherapy her daughter had relapsed and sadly a decision was made that further treatment would not be beneficial. Her daughter’s response was to write a “bucket list”. Some of the items were for herself but some related to changes that she wanted for other people including wanting parents to be fed. Her daughter could not understand why, when she was asked what she wanted to eat, that this did not extend to her mum, when her mum was in the hospital supporting her. Her daughter had not wanted mum to leave to go and eat, and no one else could come to sit with her because of the COVID restrictions. Her daughter was scared and going through gruelling treatment and that made it very difficult for mum to leave her. In addition, her treatment had affected her smell, making her feel unwell which resulted in her mum eating in the ensuite toilet as there was nowhere else to sit and eat. After her daughter died, mum had been working on items from her daughter’s bucket list, with senior representatives of the NHS. Work focused on putting in place a national programme to feed parents, improve food for children and also the provision of play specialists. In terms of food, mum had been working with UHS’ Patient Support Hub since January. Initially snack and toiletry boxes were put into every parent room but now, every children’s ward across Portsmouth and Southampton, a total of 17 wards, received food and drink every week. A charity, Sophie’s Legacy, had been set up and a trial had started that provided parents with a £4 food voucher for the restaurant, which was in addition to the support provided by the Patient Support Hub. The initiative had been well received by parents. The hope is to roll this out across the Country as looking after parents was important to enable them to support the care of their children. JD-T thanked mum for sharing noting how devastating it must have been to lose her daughter and how amazing it was that she and her daughter had wanted to support others in this difficult time. GB also thanked mum for sharing the experience and the work that was being done in her daughter’s name, which was important to continue. DAF noted how extraordinary that at the age of nine her daughter was considering the future of others. DAF asked whether mum had good links with the hospital charity and SH confirmed that he would make contact to ensure that this happened. Action: SH JT noted the importance of good facilities being available including good quality, affordable food. It was important for the Board to look at this and also to look at the estate to ensure that there was appropriate spaces provided for parents. 3. Minutes of the Previous Meeting held on 28 July 2022 The minutes of the meeting held on 28 July 2022 were approved as an accurate record of the meeting save for the following amendments: Page 2 • Page 3 – Correct spelling of Beachcroft • Page 3 – 5.3 third bullet – should read compliant not complaint. 4. Maters Arising and Summary of Agreed Actions Actions that were due had been completed. Action 763 – The complaint data was being compiled and would be sent out shortly. The remaining actions were not yet due but were being taken forward. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee KE provided a briefing following the meeting on 12 September. The External Auditors had signed off their opinion on the financial statements with a clean opinion being given. From the Internal Auditors three reviews had been completed. The incident management review had focused on smaller incidents, noting that major incidents would normally be highlighted quickly. A large number had been tested and the conclusion was that the Trust needed to work on turning the reports around within the ten-day period. The Cyber Security review was one of significant assurance. However, the report highlighted that the Trust did not have formal documentation in terms of a Cyber Security Strategy and that not much training was provided for staff. Finally, in terms of General Data Protection Regulation (GDPR) and personal information, the Trust was required to have a “record of processing activities” (ROPA). The Trust undertook hundreds of activities but did not have a ROPA for every activity and the recommendation was to review and put in place an appropriate policy to enable a more general approach for wider coverage. The final review was stage 2 of how the Trust managed and governed IT projects. The report had focused on three areas: • The initial assessment of the benefits of the IT project which had been found to be thorough and well thought out and documented. • More guidance was recommended on how to evaluate benefits particularly in terms of non financial benefits including safety benefits. • There were very few post benefit assessments being completed which would help with learning. Plans were in place to put additional controls in place by March 2023 and a review would take place as part of their follow up procedures. JT reminded members that he had arranged for Cyber training for the Board and had agreed to provide further assurance around some of the arrangements and the Internal Audit was aligned to this. JT noted that staffing arrangements would need to be reviewed as currently there was only one colleague within the digital team that worked on cyber security issues. HP informed the Board that work was already underway in terms of the work around ROPAs. Action: JT Page 3 5.2 Briefing from the Chair of the Finance and Investment Committee JB provided an update from the last meeting noting that discussions had taken place around the current financial position and the operational plan, both of which were due to be discussed in the closed board meeting. There was significant challenge particularly around the deficit position but overall there was a really good grip on exactly where the Trust currently was, with appropriate decisions being made to reflect the balance between managing the financial position, whilst continuing to support our people and activity. A number of ongoing actions around productivity were being addressed together with a clearer view of the future cash position of the Trust. Finally, JB noted that Model Hospital data had been reviewed to enable the Trust to drive efficiencies compared to other hospitals and to facilitate learning. 5.3 Chief Executive Officer’s Report DAF noted that this was the first time that the Board had met since the death of Her Majesty Queen Elisabeth II and wanted to formally recognise the fantastic public service that she had given. The state funeral, which gave an additional bank holiday, provided the Trust with some challenging operational issues, with little guidance being provided in terms of what the best approach should be. Where staff were not involved in urgent or emergency care, such as within outpatients, electives and day case procedures, they were given the choice that if they wanted to work that would be gratefully received, but similarly if they wanted to take the day off to pay their respects, they were able to. Some staff wanted to work and others wanted to take the day. More than two thirds of the scheduled activity had been undertaken. DAF thanked all staff for all of their hard work and dedication. He also noted that: • The pilot of the care village had been very successful and would be discussed further in the next item. • Junior doctor pay rates had been quite challenging and was symptomatic of where the Trust was with many members of the workforce. The Royal College of Nursing (RCN) had notified the Trust of an intended ballot for strike action. Also, the British Medical Association (BMA) had published a rate card that they wanted trusts to pay, which was in many cases, significantly above current ratees. DAF noted that there were groups of staff who had indicated that they would not work for the Trust unless paid the new rates. It was a period of instability and people were understandably wanting to protect their income which was manifesting in the behaviours that we were seeing. • The HR team had been recognised by the Chartered Institute of Professional Management (CIPD), for a National awards which was a testament to the good work that SH and his team did. • The number of COVID positive cases was increasing with around 70 currently in the hospital. Mask wearing had been re-introduced in clinical areas in an attempt to limit the number of nosocomial transmissions. Care homes were not willing to accept patients with COVID which would impact potential discharges. In terms of staff Page 4 absence from COVID this was also increasing and staff were being encouraged to have both COVID and influenza vaccinations. • UHS was in the process of finalising an IT contract which, at first glance looked like it could be a replacement for our Emergency Department (ED) IT system. The initial contract was small but included from a strategic perspective, as the Trust had recognised the potential for having a longer-term development partner. UHS remained committed to its “Best of Breed” strategy but had been struggling to recruit and retain the people needed to develop the systems and this could be a step to delivering this by working together in partnership. Ultimately this could result in UHS not only being able to bring to develop our systems but also had the potential to bring to the market a number of our IT products that we had developed. • At the previous month’s board, the Trust had been aware of its segmentation under the Single Oversight Framework (SOF) review, but had omitted to formally advise the board. The Trust remained in segment 2, with 1 being good and 4 being bad. Trusts in segments 3 and 4 received more dedicated support and oversight. This was a vote of confidence from the regulators in the Trust despite the challenges it was facing. TP noted that the BMA pay card had received much criticism and should be resisted unless there was a proper negotiation about the rates. In terms of the IT partnership this was excellent news. PG noted that the Trust had been very clear through the Local Medical Councils (LMC), and individual conversations with teams, that the Trust would not be entering into negotiations about the BMA rates. It was growing as an issue but was an untenable position to hold in front of the rest of the workforce. Meetings were taking place with teams noting that it was not just about money. PG had been clear with his medical consultant colleagues that he was not able to recommend that consultants were paid as much in one day for an overtime operating list, which was greater than the amount some staff received in a month. In a cost-of-living crisis this was wrong. Many colleagues had understood this approach but there was still many who were very unhappy. JH congratulated SH for the award noting that this was a very difficult award to achieve, with tough competition, and that to achieve it during the pandemic was outstanding. Decision: The Board noted the report. 5.4 Integrated Performance Report for Month 5 (part one) JT noted the challenges that the Trust was currently under and in particular highlighted: • The previous day had been particularly tough with every space in the hospital full and lots of patients in the ED waiting for beds. This was replicated nationally with many organisations had declared critical incidents due to the pressures being faced. It was caused by increased numbers of COVID positive patients and a big spike in the number of delayed patients in the hospital which had hit 245 patients at the start of the week, with almost a quarter of the bed base who could be treated elsewhere. Page 5 • There was a record number of cancer referrals with the waiting list being the highest it had ever been. The Trust continued to deliver more diagnostic capacity than it had ever delivered but continued to struggle with capacity in view of the increased demand. This was a very difficult position alongside a time where staff morale was low and staff were tired due to the pressures over the last couple of years. • One of the two spotlights related to cancer and the Board had a study session the following week with a deep dive. Referrals had grown by about 25% per month from around 1600 two-week referrals to consistently above 2000 per month. The backlog of patients who had breached 62 days had gone up three-fold in the last two years from around 100 to 370 patients. The overall number of patients on the cancer pathway had also doubled in this period. This was challenging for a group of patients that the Trust wanted to prioritise in terms of access to services and care. • Across the Wessex Alliance footprint the backlog remained better than the rest of the Country but it was not where we would want to be in terms of cancer services. It was likely that our performance would dip as we started to treat those patients which would impact the 62 day target, despite the levels of activity and delivering relatively well in terms of our peer groups. • There were some excellent new pathways being developed including the dermatology dream pathway which would make a significant impact on the skin pathway once implemented. Work was also being done with the cancer allowance to map what we had, against what we needed to understand better the gaps. DAF noted that the cancer performance metrics were a measure of the patients that had been treated. Once you had a number of patients above the 62 days, if you did not treat them and let them remain on the waiting list. your measure would remain strong. However, this was not the right thing to do but once you had treated them this would impact that metric which was likely to be poor over the coming months. TP noted that the waiting had continued to get bigger which would suggest that either the Trust was not coping with the numbers coming through and people were therefore waiting longer and longer or that there was a higher rate of cancer in the population. Was this as a result of COVID reducing the body’s ability to fight small cancers that would normally disappear. JD-T also noted the highest number of referrals happening in August and wondered whether there was any national modelling being done around this. JT informed members that Professor Peter Johnson would be one of the presenters at the board study session and this would be a good opportunity to explore this. Anecdotally we appeared to be seeing more sicker patients who had a number of co-morbidities presenting as more complex patients and work was underway to investigate this further particularly from an inequality lens in terms of the demographics that were being referred on the two week wait referrals. PG noted that during COVID people tended to not present which was part of the reason for a backlog of presentations but that diagnosis appeared to also be increasing. Understanding why was not yet known and a discussion in the study session would be helpful to understand that particularly better. In terms of the appraisals spotlight SH noted: Page 6 • That a key element from the People Strategy was the Trust’s ability to provide meaningful progression for our staff. From the feedback given in the staff survey many staff believed that during the pandemic they had not received the development, training or the appraisal focus that they would have wanted. • Work to address that included a multi disciplinary team who had focused on refreshing the appraisal paperwork which had been well received. The team had a wide breadth of staff including clinical, operational and trade union representatives. Previously the number of appraisals carried out had been good but the quality had been low so training for appraisals had been reviewed to improve the quality of the appraisal discussion. Whilst the Trust was better than its peers, this simply highlighted that the NHS was not particularly good at appraisals. • A pilot had been implemented to better align appraisals with objective setting to enable them to cascade down to staff better which would conclude shortly and would feed into the process. JD-T noted that Division D consistently outperformed the other Divisions in terms of completed appraisals. In addition the staff survey showed that they were the only division that achieved a green in terms of an appraisal helping staff to undertake their job. This showed a correlation between the two and wondered what was the learning was. SH noted that Division D had historically had good rates of completion and had been involved in the refresh and had highlighted the need to focus at every level of the team. JH asked whether those within Division D had better promotion and development opportunities which could link back into the value of conducting a good appraisal. SH advised that there was nothing obvious but Division D had some good engagement scores overall but this could be looked at further. GB noted that the new appraisal paperwork had removed the need to consider how an individual contributed to the values of the organisation, and although the values were still referenced, questioned how through appraisal the behaviours and values continued to sit within the process. SH noted that the review of the values work was important and it would be good to look at how that could be brought back into the appraisal process to add value. Decision: The Board noted the report. 5.5 Finance Report for Month 5 IH presented the report and highlighted: • The Trust continued to focus on the underlying deficit, which for months 1 – 4 had been around £3m which had slightly worsened to £3,5m as energy costs started to grow. A deep dive had taken place at the Finance & Investment (F&I) Committee looking at some of the actions being undertaken and some of the future forecasts before the energy cap would come in and whether this would help or otherwise. There would still be a small increase in run rate into the latter half of the year which would deteriorate the Trust’s underlying position as we entered the winter months. • The key drivers were consistent. As well as energy prices, there were some drug costs pressures as we were on a block contract, cost associated with COVID including backfill of staff together with all of the operational pressures that had already been discussed. Page 7 • Cost Improvement Programme (CIP) performance had improved following the introduction of the Cost Savings Group. The Trust was currently achieving more than 80% identified which should increase going forward. In month delivery had also been strong. Everything was being done to try and improve the financial position but there were a number of pressures that were outside our control that would impact this. • Elective recovery framework performance had dipped in line with the operational pressures discussed, but UHS continued to achieve 106%, above the required 104%. UHS was in the top Trusts both in the region and nationally in terms of activity levels compared to 2019/20 levels. However, this was not resolving the waiting list issue that continued to grow. UHS continued to do well in terms of 2019/20 levels compared to other Trusts but this did create a financial pressure. • The Trust had reported a £12m deficit. The Hampshire and Isle of Wight deficit was £53m. This was an outlier within the region, and the region was an outlier nationally. This had resulted in the system becoming an outlier in terms of financial performance which might have adverse consequences going forward including upon the SOF rating. • The underlying deficit reduced the Trust’s cash balance and that may put pressure on our future capital investment programme. KE referred to the financial risks table and asked what the difference was between the original worst case of £57m and the forecast assessments which showed, best, intermediate and worst case? IH noted that the original worstcase scenario had been presented to the Board as part of the planning submissions, to show the range of possible financial outcomes with everything that was known at the time. The current best, intermediate and worst case were the current assessments. KE noted that UHS could not control COVID costs, energy costs and inflationary measures and that this would need Treasury to provide support. IH reminded members that nationally there was a drive to find efficiencies. It was likely that many Trusts would go into deficit this year but it was not clear what the response would be to that. KE commended the work on the CIP which was a fantastic achievement. He questioned whether the position could improve further with more CIP savings. IH advised that a target date of Month 6 had been agreed in terms of everything being identified 100% and the position might improve next month. IH noted that UHS was at 106% activity levels with the national average being around 94%. The 12% from the Elective Recovery Fund (ERF) would be worth about £20m to the Trust. If the Trust had undertaken less activity the Trust’s financial position would be a lot less stark but UHS continued to put patients first and try and balance performance, money and quality. In response to a question from JD-T IH confirmed that as of today and what was currently known, UHS could still achieve the best-case scenario. DAF suggested that in view of what had happened in markets over the recent days it was unlikely that the NHS would want to approach the Treasury. UHS should proceed on the basis that there would be no financial support being provided. In those circumstances the Board would need to consider at what point more significant interventions would need to be made. Page 8 5.6 People Report for Month 5 JD-T noted that this was a new report for the board. Previously the report had been presented to the Trust Executive Committee (TEC) and following discussion in that forum a decision was made that it should be presented to the open board for discussion. SH presented the report and noted that the version before the Board was the detailed report presented to TEC. Going forward a more streamlined report, with key highlights, would be developed for the Board discussion. SH highlighted: • Some of the key actions that had been taken in relation to recruitment and retention and also the cost-of-living crisis. There had been discussions at a previous closed board meeting around concerns in relation to the recruitment and retention of certain staff groups and some actions had been put in place to mitigate those concerns. • SH highlighted the challenges around Advanced Clinical Practitioners (ACPs) and pay rates. A few local organisations including GP practices were providing a differential rate of pay with a higher pay band. In the short term this was being addressed by a recruitment and retention premium to bridge the gap, together with conducting a workforce review that would seek to understand the banding and whether there was a need for a permanent band change. However, it would be important to consider the possible impact on the change to other bands across the Trust and manage that appropriately. • UHS continued to undertake Health Care Assistant (HCA) recruitment well, but the challenge was retention. There were good pathways in place but work was needed to strengthen landing boards and increase the support available in the hubs and implement some band 2 to band 3 progression roles for those who did not want to utilise the nursing apprenticeship route. • Demand on the recruitment team had significantly increased with a 25% increase of requested support. Some additional resource had been agreed to support them both within the organisation but also to increase engagement outside of the organisation. • In terms of cost of living, SH had been undertaking a lot of work with partners across the Trust including trade unions and listening to staff voices. There were a number of elements that were not under the Trust’s control including the national pay award and the rising energy crisis so the approach being taking was to take a balanced and fair approach. A number of things would be implemented which would be highlighted to all staff. A substantial discount was being negotiated in the restaurant to help people to eat a broad range of foods at competitive prices. The cycle to work scheme was being expanded, and there was some targeted support for those with high mileage within the organisation. For the 200 or so families who used the nursery the price was being rolled back to April this year. • The Trust already has a range of general support which would be expanded to make sure that we were targeting the right people. Through a partnership with the ICS we were linking up with the Citizens Advice Bureau to provide really high quality financial advice to our staff. We were focusing on crisis, and working with the Charity, had set up a hardship fund of £20,000 which would be distributed to the most challenging cases where staff had been identified as a particular Page 9 hardship case they would be able to eat free at the restaurant. Arrangements had also been made with a local charity to provide vouchers and food parcels. Discussion had taken place as to whether a food bank should be set up on site which logistically would have been difficult, so the decision to work with the charity was agreed to be the best approach to deliver that service for us. • Discussions had taken place at the Trust Executive Committee (TEC) who had fully supported the measures noting the impact on the nonrecurrent spend. KE suggested that this was a very sensible, targeted group of things to support our people. However, asked if the cost of £2.3m was currently included in the financial reports. IH advised that it was not included although some of the nonrecurrent elements had a funding source so would not hit the underlying position. In terms of annual leave buy out there were accruals from previous years. However, there were some recurrent costs. The measures were targeted, proportionate and in line with the Trust’s values for the current pressures being faced and if the Trust did not do anything it would likely increase costs or consequences elsewhere. DAF noted that the report was the same as presented to the TEC at which there had been a more detailed conversation. It would be helpful to understand which areas of the report were more relevant and appropriate for the Board conversation which could be discussed at the next People and OD POD) Committee meeting. Action: SH. JH supported the proposals within the paper and noted that they had also been presented to the People and OD Committee (POD). POD would be tracking the progress of each of the initiatives to ensure that they were delivering as anticipated. JH asked if the Trust had looked at what others were doing to ensure that we were doing everything possible for our staff. SH confirmed that discussions had taken place locally and that the Trust was one of the first to implement the range of measures which were similar to those of others. Nationally, there had been a push to have a collective response, noting that the NHS employed 1.5m people and that there would be national support that would be available shortly. TP noted the importance of having a people report at the Board and whilst the contents were good suggested that they could be presented in a more accessible way. FM also noted the importance of the report and discussion but wondered what staff morale was. If the finance, performance and people report were considered as a whole it was clear that staff were facing a lot of pressure and there was insufficient staff due to high turnover. The volume of patients was increasing which meant that the staff that the Trust did have, had to work harder and longer with pay that was not great and a cost-of-living crisis to deal with. This must have an impact on staff morale and was there also an impact on patient care? SH noted that morale was challenged which was recognised in the executive updates. The Trust undertook a quarterly staff survey alongside the current national annual staff survey and those results have been included within the report. The recent results discussed motivation, engagement and advocacy in Page 10 the organisation and UHS scores were still consistently in the top 10 of the NHS. However, the entirety of that engagement score was deteriorating. Morale was challenged and how that impacted on care was discussed in other forums. GB chaired the Quality Governance Steering Group (QGSG) which fed into the Quality Committee and focused on quality whether that be from the engagement of our staff or other challenges. GB suggested that it was a mixed picture. People enjoyed working as a team and we can see them pull together and work as a team through the challenges. There were a number of different pockets in the organisation who believed that they were in a worst situation following the pandemic and it was important to move out of that space and recognise this as a whole. In terms of quality, it was important to retain a close focus on quality and in some other Trusts they were starting to experience a significant challenge with regards to their quality indicators. At UHS there were some potential early indications that were being closely monitored. Without a doubt staffing levels, and the way in which we looked at the wards, impacted on patient experience and outcome. JD-T noted that one of the proposals was for staff to be able to sell back annual leave and being able to easily access the bank but if this was considered in the wider context, we had staff who were tired and not able to take leave as they had sold it, and were looking to work extra hours on the bank. How did the Trust manage and balance this? How should we look at the overarching risks for the workforce, and consequently patient care and performance, and what were the things that we needed to do to balance that. It would be helpful if the report could address some of those challenges to help the Board’s understanding. In addition JD-T asked NEDs to feedback what they would want to see within the report to enable an effective discussion. Action: SH and All NEDs JH asked about exit surveys and wondered if there was any information from them that could support our approach. SH advised that approximately 30% of staff completed exit surveys which needed to be increased. Pay for the lower paid staff had become an issue. SH reminded members that he chaired the ICS people officers group and that group had been looking at how collectively they could support retention and were looking to purchase better exit surveys for the system pulling together their collective buying power. Decision: The Board noted the report. 5.4 Integrated Performance Report for Month 5 (part two) Having noted the previous discussions under items 5.5 and 5.6 JD-T suggested that a discussion on the remaining of the IPR would be helpful and the following questions and comments were made: • JB noted that on pages 31 and 35, F1 – F5 this suggested that in terms of digital we believed that this was going to transform our efficiencies but it was not clear what the metrics indicated nor were some of them very high. PG suggested that there was an amazing resource in my medical record which we were not really making the most of. Work was needed to raise awareness with both patients and clinicians. Having used it as a patient it had been really helpful and enabled him to go paperless. JT noted that there was a business case that was overdue Page 11 for my medical record around how we industrialised it across the Trust which should provide some huge benefits and would bring a timeline back as to when this would happen. Action: JT JT noted that there was some big digital change happening with the rolling out of speech recognition and some E tools. In addition it would be helpful to look at the indicators to understand whether they were the right ones and review them as part of the digital updates which could be discussed at F&I. Action: JT The Board discussed the importance of giving people an overwhelming reason to access my medical record noting that the NHS App had initially been used for COVID vaccinations but could now enable people to order prescriptions and book appointments. JD-T noted the Serious Incident reports and the number of harm falls which looked higher than previously and wondered in terms of the pressures we were seeing and the issues around workforce should the Board be concerned about this? GB advised that it had recently been falls awareness week. There had been a number of successful programmes in the Trust including bay watch, but with reduced staffing numbers that had became a challenge and some more deliberate high impact actions were needed to reduce those falls. A deep dive into this would be brought to a future meeting. Action: GB GB confirmed that COVID numbers were rising. There were 66 patients with COVID some of whom were both asymptomatic and symptomatic. 5.7 Break The break took place prior to the Safeguarding Annual Report. 5.8 Safeguarding Annual Report 2021-22 and Strategy 2022-25 JDT suggested that the strategy should be discussed first noting that both had been discussed at the Quality Committee. KMcG presented the strategy which had previously been presented to the Trust Board two years ago before Covid. The strategy had been reviewed and updated in line with new legislation and aligned to UHS values and now included maternity services. Some of the strategy linked to children and adult reviews and making safeguarding personal together with our partners and developing stronger links within maternity, the emergency department and the wider hospital. Joining this up with the domestic abuse strategy and ensuring that we were always improving particularly around training and education including level 3 requirements. In terms of the Annual Report from a children’s perspective there were three main highlights: Page 12 • A significant increase, from 3700 to 6004, in the number of information sharing forms (ICF) which come through the ED where a child may possibly be at risk. In particular numbers had increased in the number of children presenting with mental health problems, particularly the 0 – 4 age group. This had been discussed at the Health Safeguarding Looked After Children Partnership who were looking at the 0 – 19 service provision which had changed significantly with COVID and a possible pattern of children of parents accessing through ED rather than going via their GP. • In terms of mental health, for any child who presented in the ED with a mental health condition an ICF would be completed. The number of presentations remained high. Alongside this the number of deliberate harm incidents had risen from 676 to 898, drugs and alcohol referrals had risen as had assaults over the preceding year. • Level 3 safeguarding training was at about 61%. There were two main reasons for this which was capacity and demand for the service and also a change of reporting requirements impacting just over 2000 staff. Training was on the Integrated Care Board (ICB) Risk Register as it was a wider system issue. In terms of the Annual Report for adults CM highlighted the following: • A 31% increase in safeguarding activity from the previous year with a 162% increase in Section 42 inquiries. This was due to a number of reasons including the impact of COVID including the removal of social distancing rules. • A 35% increase in the number of allegations made against people in a position of trust which was something that was being seen across other local provider organisations. These were highly sensitive cases and required significant safeguarding oversight and management alongside collaboration with HR colleagues and the relevant clinical areas, which had a significant impact on the team. • The creation of a new Mental Capacity Act (MCA), Deprivation of Liberty (DoL) and Liberty Protection Safeguards (LPS) team who supported people over the age of 16. Both locally and nationally this was one of the first teams that had been established. The team had worked to embed MCA as every day business which was key to the preparation for when LPS become law later next year or early the following year. • In terms of Learning Disability and Autism there was a lack of local provision which had been acknowledged by the ICS and work was underway in relation to service review and what this needed to look like going forward. GB thanked the team noting how hard they worked to safeguard vulnerable adults and children. GB referenced the Panorama programme that had aired the previous night in terms of a number of safeguarding issues against a Mental Health Trust. Whilst often allegations against staff were not grounded they were taken very seriously and investigated thoroughly. JB noted the 35% increase against staff and wanted to understand what the outcomes of the investigations were and whether they were justified and whether allegations were being made against different groups. CM advised that one of the key areas of allegations focused on restraint and that the level Page 13 of restraint applied was disproportionate. These would always be reviewed. Security staff worked in pairs and wore body cameras which would always be reviewed. There had not been any cases recently where that had proved to be an issue. Although there had been a big increase the total number of cases was 38 so not large numbers. The previous year there had been 23 cases. CC questioned what element of this sat within the Trust and what sat with the ICS? SH noted the importance of remembering the broader picture. Nationally there had been a rise of safeguarding incidents, but it was important to remember that our workforce formed part of that population and had struggled with lockdown and were experiencing hardship. JD-T noted the need for a system approach to manage the increased mental health demand. However, safeguarding was a key focus for the Care Quality Commission (CQC) inspections post COVID, and a local provider had recently been deemed to be inadequate due to safeguarding issues and was an issue for UHS to pay particular attention to. KMcG noted that through legislation children had the Local Area Designated Officer (LADO) which was lacking in adults, which provided a really strong link with that external partner. TP noted that there had been a detailed presentation on this in the Quality Committee. This was a national trend in increased safeguarding problems. Whatever pressure we are put under it was important not to let our safeguarding procedures slip and it needed to be protected to ensure that it worked well. Decision: The Board received the report. 5.9 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance PG presented the report which was a statement of compliance with the medical regulations and had a robust and strong process in place. PG noted that a new appraisal system had been introduced which had been well received and enabled the ability for medical staff to collect all of their appraisal information within one system instead of the previous three systems. This was beneficial for not only staff but also for those managing the process as it provided real time feedback and information both from a quality assurance perspective but also would enable better management of the process and improve appraisal rates in the future. JD-T asked whether the doctor appraisal information was included within the IPR information that the Board received and SH confirmed that it was reported separately but included in the report and currently stood at 76.7%. CC suggested that the system was good but asked whether everyone was using it. PG confirmed that the system was a mandatory one and would be the only system going forward in the future. In terms of how many staff had undertaken the process this was a little ahead of the rest of the staff. However, the system enabled us to keep better track as people would need to have completed four appraisals within the previous five years to go forward with revalidation which provided a good incentive to keep on top of this. Page 14 JD-T asked for Board members to confirm that they approved the statement of compliance. Decision: The Board noted the report and approved the statement of compliance. 5.10 Clinical Outcomes Summary PG introduced the comprehensive summary noting that the clinical lead who had ran the service for a number of years, had now left UHS and a process of recruitment was currently underway which would provide an opportunity to refresh and review. DW presented the paper and focused on the outcome programme which was unique to UHS, with 64 services out of 86 reporting their outcomes. A total of 484 outcomes had been reported all of which had been reviewed by TP via the Quality Committee. There was a thriving clinical audit programme in place. The outcomes reported per care group covered a large proportion of patients and dealt with both national and international work. In particular DW highlighted: • The Research and Development (R&D) team and the work that they had undertaken internationally on the COVID booster trial. • The Bone Marrow Transparent unit. • Maternity and the nest support teams who focused on women who may need additional support because of serious mental illness, or they were from socially challenging situations, or were non-English speaking, addiction, were homeless or were suffering from domestic abuse and other difficult situations. 12% of patients that were being seen in maternity required nest care. KE asked why 18 services were not reported and DW advised that it was because they did not have the mechanisms in place to know what their outcomes were and work was underway to support them to develop those processes. KE asked whether any of the reds within the report were really poor and JD-T noted that the data used was for 2020 and did not understand why it was so out of date. TP advised that data was provided from national audits was often two years behind, because there was a year of collection, a year of analysis and then it would be published. Within his experience he had never come across a hospital that had measured nearly 500 clinical outcomes let alone p
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Papers Trust Board - 11 March 2025

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

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

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Researchers in Southampton are leading a groundbreaking study into whether or not a drug used to treat heart failure could save the sight of patients with a currently untreatable eye condition.
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/AboutTheTrust/Newsandpublications/Latestnews/2017/April-2017/Southampton-researchers-use-heart-drug-to-treat-eye-disease-in-groundbreaking-study.aspx
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