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Restricted pedestrian and vehicle access on site, Saturday, 18 February

Description: On Saturday, 18 February a lorry will be arriving on site to lift and relocate two containers. This will restrict pedestrian
Url: /AboutTheTrust/Newsandpublications/Latestnews/2017/February-2017/Restricted-pedestrian-and-vehicle-access-on-site-Saturday-18-February.aspx

Improvements to crossing at Southampton General Hospital emergency department

Description: Patients and visitors to Southampton General Hospital are being advised of roadworks that are taking place on one of the main
Url: /AboutTheTrust/Newsandpublications/Latestnews/2019/November/Improvements-to-crossing-at-Southampton-General-Hospital-emergency-department.aspx

Bowel preparation for your child's colonoscopy - patient information

Description: This factsheet explains how to prepare your child's bowel before a colonoscopy.
Url: /Media/UHS-website-2019/Patientinformation/Childhealth/Bowel-preparation-for-your-childs-colonoscopy-2737-PIL.pdf

Rescheduled temporary closure of orange car park, 23 to 25 August

Description: The orange car park at Southampton General Hospital will be temporarily closed from 6pm Friday, 23 August to 8pm on Sunday, 25 August, to enable the delivery and installation of a crane for the general intensive care unit (GICU) extension building works.
Url: /AboutTheTrust/Newsandpublications/Latestnews/2019/August/Temporary-closure-of-orange-car-park.aspx

Records management policy

Description: Records Management Policy Date Issued: Review Date: Document Type: 9 May 2018 19 April 2021 Policy Version: 6 Contents Paragraph 1 2 3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 4 5 6 7 8 9 Appendices Appendix A Appendix B Appendix C Executive Summary Introduction, Scope and Purpose Definitions Details of Procedure to be followed Regulatory and legal framework The Records Information Lifecycle Record Creation Handling and Using Records Record Closure and Retention Appraisal Disposal Additional Guidance on Specific Record Types Roles and Responsibilities Related Trust Policies Communication Plan Process for Monitoring Compliance/Effectiveness of this Policy Arrangements for Review of this Policy References Page 2 3 4 5 5 6 6 7 9 10 11 11 13 14 14 15 15 15 Page 17 21 22 Record Creation and Filing Procedures Medical Record Keeping Standards List of Record Types listed in NHS retention Schedule Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Page 1 of 26 Executive Summary 1. There is a need to manage Trust records efficiently and effectively to support day to day operational and business activity and meet certain legal requirements. As we create and collect increasing amounts of information about our patients, staff and business activities it is vital that are able to organise, securely store and retrieve this information when required. 2. As we manage the incremental change from traditional/paper based record keeping to electronic/ digital systems we encounter new challenges, however the key principles of records management outlined in this policy continue to apply to these new storage mediums. Where different or additional guidance is required this is provided. 3. This policy is structured to provide staff with guidance on managing records through their life cycle from creation to disposal. Adherence to this guidance will support all aspects of Trust business and help the Trust comply with its duties as a public body subject to the Public Records Act (1958) and the Freedom of information Act (2000). 4. The Records/Information Life Cycle describes a regime designed to ensure information is managed from the point that it is created to the point that it either destroyed or permanently preserved as being of historical or research interest. The cycle is illustrated in this diagram: 5. In summary this policy: Defines duties and responsibilities in regard to records management in the Trust Outlines the key legal obligations and statutory provisions that apply to records created and used within the Trust Provides a procedural Framework with guidance to encourage best practice in records management within the Trust Describes the `Information Life Cycle' and highlight best practice to be followed at each stage of the cycle from creation to disposal. Page 2 of 26 1. Introduction, Scope and Purpose 1.1 Introduction 1.1.1 Records Management is the process by which an organisation manages all the aspects of records whether internally or externally generated and in any format or media type, from their creation, all the way through to their lifecycle to their eventual disposal The Trust's records are its corporate memory, providing evidence of actions and decisions and representing a vital asset to support daily functions and operations. Records support policy formation and managerial decision-making, protect the interests of the Trust and the rights of patients, staff and members of the public. They support consistency, continuity, efficiency and productivity and help deliver services in consistent and equitable ways. Adherence to the guidance provided in this Policy will provide the Trust with a number of benefits including: better use of physical and server space; better use of staff time; improved control of valuable information resources; compliance with legislation and standards; and reduced costs. This document sets out a framework within which Trust records can be managed and controlled effectively, and at best value, commensurate with legal, operational and information needs. 1.1.2 1.1.3 1.1.4 1.2 Scope 1.2.1 This policy applies to Trust records held in any format including: Paper Photographs slides and other images Microform microfich and microfilm Audio and video tapes, cassettes CD ROM etc Computerised records Scanned records Text messages and social media Websites and intranet sites that provide key information to patients The majority of Trust members of staff will create records during the course of their day to day activity. Aspects of this policy will therefore apply to most members of staff, with specific responsibilities applying to department heads and managers for the management of local records created stored or held in their areas of responsibility. At the time of publication of this policy preparations are being made to ensure the Trusts compliance with the implementation of the European Union General Data Protection Regulation (GDPR) in May 2018. To date no direct impact on the records procedures outlined in this policy has been identified as a consequence of the introduction of GDPR. As these preparations progress any identified changes required to records management policy and procedure will be made. The Trust is also in the process of changing to a digital format of medical record recording and storage using the Onbase Electronic Document Management System (eDMS). An incremental roll out of the system to care groups has started but is at an early stage. 1.2.2 1.2.3 1.2.4 Page 3 of 26 1.2.5 1.2.6 This policy makes an occasional reference to this significant change and the key principles for records management outlined in this policy (storage, retention etc) still apply to the records created and stored in Onbase. As the incremental roll out of Onbase eDMS progresses and operational procedures are finalized this policy will be reviewed and the need for changes to be made or additional operational policies and procedures to be published will be agreed and implemented. 1.3 Purpose 1.3.1 The purpose of this policy is to: Define duties and responsibilities in regard to records management in the Trust Outline the key legal obligations and statutory provisions that apply to records created and used within the Trust Provide a procedural Framework with guidance to encourage best practice in records management within the Trust Describe the `Information Life Cycle' and highlight best practice to be followed at each stage of the cycle from creation to disposal. Definitions 2. Term Records Management Meaning Applied in this Policy A set of activities required for systematically controlling the creation, distribution, use, maintenance, and disposition of recorded information maintained as evidence of business activities and transactions. Record Information created, received and maintained as evidence and information by an organisation and person, in pursuance of legal obligations or in the transaction of business. (ISO Standard 154891:2016). General Data Protection European Union Directive which will replace the Data Protection Act Regulation (GDPR) (1998) in UK law, enforceable from 25th May 2018. Designed to harmonise data protection regulation across the European Union. Electronic Document A software program/system that manages the creation, storage and Management System control of documents electronically. (eDMS) Information Life Cycle A term that describes a controlled regime in which information is managed from the point that it is created to the point that it either destroyed or permanently preserved as being of historical or research interest. Public Authority An organisation within the categories listed in Schedule 1 to the Freedom of information Act defined as `a body that appears to be exercising functions of a public nature or who are providing, under contract with a public authority, any service whose provision is a function of that authority. The Trust is a Public Authority. Metadata Data that describes information about other data. e.g. author and creation date of a record are elements of its metadata. Record Classification Means by which a record keeping system arranges or organises Scheme records to enable appropriate management controls to be applied and support accurate retrieval of information. e.g. a filing index. Page 4 of 26 Public Records Administrative and departmental records belonging to Her Majesty, in the UK or elsewhere, in right of Her Majesty's Government, and in particular records of or held in any government department and records of offices, commissions or other bodies under HMG in the UK. (Public Records Act 1958). All Trust records are public records subject to the Public Records Act (1958) Data Subjects An individual who is the subject of personal data. Patient Administration Electronic system used to hold non clinical details about Trust System (PAS) patients (demographics, GP details, contacts etc). Electronic Clinical A module of the Trust PAS used to record the movement of patient Record Tracking (eCRT) Health Record Folders within UHS and partner organisations. Record closure The process followed to make a record inactive when it has ceased to be in active use other than for reference purposes. Record retention The process of keeping a record for a period of time for administrative, legal, fiscal, historical, or other purposes. Record appraisal The process of deciding what to do with a record when the business use has ceased. The outcome of record appraisal will be either: destroy/delete, retain for a further period or transfer to a Place of Deposit. The National Archives A non-ministerial department, and the official archive and publisher (TNA) for the UK Government, and for England and Wales. TNA publishes advice and guidance on information and records management. Place of Deposit (POD) Record Archive storage location appointed by the Secretary of State for Culture Media and Sport. Usually a public archive service provided by a Local Authority. Corporate Records Records of business processes such as accounting, procurement, staff management and estates maintenance. In NHS organisations this term covers all records that are not patient/care records. Permanent preservation A process followed to place a record in an archive storage location allowing public access to records of historical administrative or local importance. Record Disposal The destruction, deletion or transfer for permanent preservation of a closed record British Standard 10008- The British Standard that outlines best practice for the 2014 Evidential Weight implementation and operation of electronic information and Legal Admissibility management systems, including the storage and transfer of of Electronic Information information. Information Governance An umbrella term relating to the processes and systems used by organisations to manage the information they hold. In the context of the NHS, it specifically refers to the processes and procedures used to ensue confidentiality, security and accuracy of information. 3. Details of Procedures to be Followed 3.1 Regulatory and Legal Framework 3.1.1 Under the terms of the Public Record Act 1958 all records created in the Trust are regarded as public records. The act imposes a statutory duty on the Trust to make arrangements for the safe keeping and eventual disposal of records. The ownership and copyright of records created within Trust lies with the Trust and not the individual who has created them. Page 5 of 26 3.1.2 3.1.3 3.1.4 As a Public Authority subject to the Freedom of Information Act the Trust has a duty to follow the Code of Practice for Records Management published by the Lord Chancellor in accordance with section 46 of the FOIA. The code provides guidance to public authorities on keeping, managing and destroying records. The Data Protection Act sets in law how personal and sensitive information may be processed and largely influences the way we handle care records. Further guidance on the confidentiality aspects of record keeping is provided in the NHS Confidentiality Code of Practice and the Trust Data Protection and Confidentiality Policy. The Records Management Code of Practice for Health and Social Care 2016 provides records management guidance for NHS and Social Care organisations based on current legal requirements and professional best practice. The Trust is committed to following the guidance issued in the code of practice and the procedures outlined in this policy are largely based on the guidance included in this Code of Practice. 3.2 The Records Information Lifecycle 3.2.1 The records or information lifecycle is a term that describes a controlled regime in which information is managed from the point that it is created to the point that it either destroyed or permanently preserved as being of historical or research interest. The cycle is illustrated in figure 1 Figure 1. The Information Lifecycle 3.2.2 Procedural guidance associated with each stage of the cycle is included in subsequent sections 3.3 Record Creation 3.3.1 ISO 15489-1:2016 Information and Documentation � Records Management describes the characteristics of `Authoritative Records' as being authentic, reliable integral and useable. Table 1 below expands on these definitions. Page 6 of 26 Table 1. Record Characteristics Record Characteristic Authentic How to Evidence It is what it purports (claims) to be To have been created or sent by the person purported to have created or sent it and To have been created or sent at the time purported. Full and accurate record of the transaction/activity or fact Created close to the time of transaction/activity Created by individuals with direct knowledge of the facts or by instruments routinely involved in the transaction /activity. Complete and unaltered Protected against unauthorised alteration Alterations after creation can be identified as can the persons making the changes. Located, retrieved, presented and interpreted The context can be established through links to other records in the transaction/activity. Reliable Integrity Useable 3.3.2 3.3.3 3.3.4 3.3.5 By organising records in a file system or classification scheme elements of `Metadata' are associated with each record which helps maintain the characteristics described above. Metadata in its simplest form would identify the creator, creation date and subject of a record but can be expanded to include additional information such as destruction date, identifiers and accessibility. Classification schemes can be a simple arrangement of files and folders on a Network drive increasing in sophistication up to a full blown Electronic Document and Records Management System such as the Onbase edMS being introduced to store patient records in the Trust. All Trust records should be stored within an appropriate classification/filing system after creation. This will ensure they remain secure and accessible from the outset and be available to support Trust business activity. A more comprehensive guide for users covering the creation and filing of records is attached at Appendix 1. 3.4 Handling and Using Records 3.4.1 Record Keeping 3.4.1.1 When completing entries in or creating any form of records the following general guidance should be applied: Be factual, consistent and accurate Write clearly and in such a way that text cannot be erased Write in such a way that any alterations or additions are dated, timed and signed in such a way that the original entry can still be read. Page 7 of 26 3.4.1.2 Healthcare professionals may be subject to additional record keeping codes of practice set by their professional bodies. The Academy of Medical Royal Colleges has published a set of generic medical record keeping standards which are reproduced at Appendix 2. All entries in Trust care records should conform to these standards. 3.4.1.3 Rights granted to members of the public by the Freedom of Information Act and to patients and staff under the Data Protection Act can result in copies of corporate records being placed in the public domain and data subjects obtaining copies of records containing information about them. Providing record entries are factual and accurate and personal records do not include any unnecessary and/or derogatory comments record disclosure should not create any additional issues. 3.4.2 Confidentiality and Access 3.4.2.1 All Trust records are public records and thus are subject to a number of statutory provisions regarding confidentiality, access and disclosure. Patients entrust the NHS or allow it to gather sensitive information relating to their health and other matters as part of their seeking treatment. They do so in confidence and they have the legitimate expectation that staff will respect this trust. It is essential, if the legal requirements are to be met and the trust of patients is to be retained, that the NHS provides, and is seen to provide, a confidential service. 3.4.2.2 Specific guidance on patient confidentiality issues is provided in the Trust Data Protection and Confidentiality Policy. Further advice on all aspects of patient confidentiality and the application of the Data Protection Act (1998) on the way we handle records in the Trust can be obtained from the Trust Information Governance Manager. 3.4.2.3 The Data Protection Act (1998) makes provision in law for `data subjects' (e.g. patients and members of staff) to obtain copies of otherwise gain access to information held about them. The Trust Access to Records Policy covers this aspect of records management and further advice on the procedure can be obtained from the Trust Information Governance manager. 3.4.2.4 In 2000 the government introduced the Freedom of information Act providing members of the public with the general right of access to recorded information held by a wide range of bodies across the public sector. The effect of this legislation is to make it possible for people to obtain copies of a wide range of Trust records that in the past would have remained confidential. The Trust Freedom of Information Policy covers this aspect of records management and further advice on the procedure can be obtained from the Trust Information Governance manager. 3.4.3 Record Tracking 3.4.3.1 Ideally the movement and location of all records should be controlled to ensure that a record can be retrieved at any time and there is an auditable trail of record transactions. This is best achieved using some form of record tracking system to record the movement of records between locations. 3.4.3.2 It is the policy of the Trust that patient health record folders are tracked using the PAS record tracking component (electronic casenote record tracking e-CRT.) Users are provided with training to use e-CRT prior to being granted access to the system. 3.4.3.3 While electronic records do not require tracking as such, control must be exercised when hard copies are produced. If separate clinical casenotes are produced from electronic systems to form a filing system individual record movements should be tracked to aid retrieval and avoid loss of data. 3.4.3.4 For most areas, where movement of records is restricted, paper based systems may be employed, using registers or tracer cards to record the relevant information. Page 8 of 26 3.4.3.5 When making arrangements to move records which contain personal or sensitive information to destinations external to the Trust (including archive storage) consideration needs to be given to security and confidentiality and a means of dispatch chosen that affords an adequate level of security. (See Trust Data Protection Policy for further guidance.) 3.4.4 Record Storage 3.4.4.1 When not required for operational purposes records should be kept in a secure storage area. Records in current use should ideally be stored close to the point of use while records no longer in current use can be transferred to secondary or archive storage more remote from the operational area. 3.4.4.2 Records should be stored in an appropriate environment to ensure they remain fit for purpose during their expected period of retention. When evaluating the suitability of a location for record storage the following points should be considered: Environment. Is the location suitable for the type of material being stored? Is the area free from hazards that may cause the records to deteriorate or place at risk staff that may need to access the records? i.e. excessive dust, damp, restricted access. Security. Is the level of security offered by the location acceptable for the type of record being stored? Ease of Access. Can records be easily located and retrieved? Some restrictions on access may be acceptable for records that are not frequently recalled. Layout. Consideration should be given to the design of the storage location to ensure the most cost effective use is made of the space available. 3.4.4.3 External storage companies provide an alternative to local storage and in the short term can prove a cost effective alternative in areas where record storage space is at a premium. The Trust has negotiated a contract for external record storage with a Restore, a national provider with storage premises located a few miles East of Southampton. Advice on external storage options and alternative strategies such as archiving records to digital formats can be obtained from the Trust records manager. 3.4.4.4 A comprehensive record should be maintained of any records sent for commercial storage including a proposed date for review/destruction. A mechanism for reviewing these records for disposal should be developed and implemented to ensure records are not retained longer than necessary. 3.4.4.5 Digital information should be stored in such a way that throughout the lifecycle it can be recovered in an accessible format. Over time such changes as migration to new formats can cause links to other documents and embedded documents to fail to open impacting the integrity of the record. Any changes to the electronic storage systems used to hold Trust records should only take place after full consideration of the impact on the records held and successful testing of retrieval of transferred records from the new version/system. 3.5 Record Closure and Retention 3.5.1 A record should be closed when the business use for that record ceases. Following closure NHS records are subject to a minimum period of retention. The length of the retention period varies by record type and is based on legal and regulatory requirements and the assessed importance of and likely need to access the type of record. Certain types of corporate records (e.g. finance, meeting records etc) will follow annual cycles with existing records closed following year end and new records created for the new year (calendar or financial). 3.5.2 Page 9 of 26 3.5.3 3.5.4 3.5.5 3.5.6 3.5.7 3.5.8 3.5.9 Paper record folders should be clearly marked with the date of closure and planned review/disposal date. Closed records in electronic storage systems should hold this information as part of the record's metadata and/or the record moved to another area of the system reserved for closed records. For patient care records the recognised date of record `closure' is normally the date of the patient's last attendance for treatment. Where a patient has died subsequent to treatment at the Trust the retention period applicable to deceased patient records (8 years) may be applied from the date of death, if this results in a shorter retention period. Minimum retention periods for NHS and Social Care records are set out in Appendix 3 of the Code of Practice which can be accessed via this link: https://digital.nhs.uk/codes-of-practice-handling-information Periods of retention between 6 months and 20 years are listed for NHS record types organised by functional groups. A list of the NHS record types with minimum retention periods listed in the Code of practice is reproduced at Appendix 3. The majority of adult patient health records are subject to a minimum retention period of 8 years. Health records for Children, Obstetric records, mental health (including psychology) records, and records recording treatment for cancer are all subject to longer periods of retention. The period of retention is measured from the start of the calendar year following the record closure date. e.g. record closed 1 July 2017 subject to 5 year retention period. Period starts 1 Jan 2018 and ends 31 Dec 2022. The code of practice lists minimum periods of retention and in most cases it will be appropriate to destroy records immediately once the period has expired. Retention beyond the recommended period is permitted with good reason but if personal data is held `longer than necessary' the Trust may breach a provision of the Data Protection Act. The Public Records Act 1958 states no public record can be retained after closure for a period in excess of 20 years without permission from the Sec of State for culture Media and Sport. However, a legal exemption applies for individual NHS staff and patient records to meet the extended (20 years plus) periods of retention listed for these records in the Code of Practice. 3.6 Appraisal 3.6.1 When the minimum retention period for a record or set of records has passed it should be subject to an appraisal. The purpose of the appraisal process is to: Identify records of public interest worthy of permanent preservation by transfer to The National Archives or a local Place of Deposit. Identify records to be retained for a longer period To confirm that records not meeting above criteria should be deleted or destroyed. A small percentage of Trust records will meet the criteria for selection for permanent preservation. The preservation of a small subset of key records is designed to enable the public to understand the working of the Trust and the impact on the population it serves and to preserve information likely to have long term research value. The Code of Practice includes guidance on the records that should be considered for preservation in the schedule of minimum retention periods. The suggestions for consideration include Trust Board and other key committee papers, key policies and strategies and records of major building works. 3.6.2 3.6.3 Page 10 of 26 3.6.4 3.6.5 The process of selection of key corporate records for permanent preservation will be managed by the Trust Records manager and the Director of Corporate Affairs who will agree with the Trust's local Place of Deposit (POD), Southampton City Archives, which Trust records merit transfer. Clinical records are problematic to preserve permanently in an archive and due to confidentiality issues personal health records cannot normally be accessed by the public for considerable periods of time following transfer. This does not prevent appropriate sets of clinical records being considered for permanent preservation and the Code of Practice provides some specific guidance on this process. 3.7 Disposal 3.7.1 Following appraisal any records not selected for permanent preservation or a longer retention period should be disposed of. No information should be destroyed if it is the subject of a request under the DPA and/or FOIA or any other legal process, such as an inquest following a death. Paper records should be destroyed securely through a local process of cross cut shredding or using the Trust confidential waste disposal service or other similar secure disposal service. Destruction of digital information is more challenging. At present there are two ways of permanently destroying digital information and these are either: overwriting the media a sufficient number of times or the physical destruction of the media. Further advice about the destruction of digital records can be obtained from the Trust Informatics service. Where decisions are made to destroy/dispose of a series or bulk number of Trust records a record of the decision and the details of the records disposed of should be maintained. 3.7.2 3.7.3 3.7.4 3.8 Additional Guidance on Specific Record Types 3.8.1 E-Mail 3.8.1.1 Personal e-mail accounts tend to be structured according to personal preference and the data stored is not searchable and organised in a systematic way, making e-mail accounts unsuitable for record storage purposes. 3.8.1.2 E-mail accounts should not be used to file records on a permanent basis but should be regarded as transient storage areas for working documents. E-mails or documents distributed by e-mail that need to be retained as Trust records should be copied to the appropriate paper or electronic registered file system and the e-mail copy destroyed as soon as practicable. 3.8.1.3 Where email is declared as a record or as a component of a record, the entire email must be kept including attachments so the record remains integral - for example an email approving a business case must be saved with the business case file. Emails that are the sole record of an event or issue, for example an exchange between a clinician and a patient, should be copied in to the relevant clinical record rather than being simply deleted. 3.8.2 Scanned Records 3.8.2.1 Where paper records are scanned, the main consideration is that the information can perform the same function as the paper counterpart did, and like any evidence, scanned records can be challenged in a court. This is unlikely to be a problem provided it can be demonstrated that the scan is an authentic record and there are technical and organisational means to ensure the scanned records maintain their integrity, authenticity and usability as records, for the duration of the relevant retention period. Page 11 of 26 3.8.2.2 Complying with the standard, `BS 10008 Electronic Information Management Ensuring the authenticity and integrity of electronic information' provides one method of ensuring and demonstrating that electronic information remains authentic. The scanning of Trust patient records for inclusion in the Onbase eDMS patient record system is being carried out in accordance with this standard. 3.8.2.3 For smaller scale local record scanning projects compliance with the full scope of BS 1008 will not be the appropriate methodology. Methods that can be employed to ensure that scanned records can be considered authentic include: A written procedure outlining the process to scan, quality check and any destruction process for the paper record Evidence that the process has been followed An audit trail or secure system that can show that no alterations have been made to the record after the point they have been digitised Fix the scan into a file format that cannot be edited such as Portable Document Format (PDF). 3.8.2.4 Providing scanning is carried out to an acceptable standard with an element of quality assurance included in the process it is Trust policy and normal practice that original documents should be destroyed after scanning. This prevents issues with two versions of the same record existing (original and scanned) and maximises the benefits accruing from scanning paper records. 3.8.2.5 There may be some local exceptions to this practice with appropriate justification. 3.8.3 Staff Records 3.8.3.1 Staff records should hold sufficient information about a staff member for decisions to be made about employment matters. The nucleus of any staff file will be the paperwork collected through the recruitment process and this will be expanded over time with additional material added by line managers. 3.8.3.2 Upon termination of contract, records must be held up to and beyond the staff member's statutory retirement age. On contract termination line managers should return the employees file to HR department for retention until the employee's 75th birthday or 6 years after leaving whichever is the longer. To reduce the burden of storage a summary record may be prepared and held. 3.8.4 Records of non NHS Funded Patients 3.8.4.1 Records of individuals who are not NHS funded held in the Trust record keeping systems must be kept for the same minimum retention periods as other records outlined in this Code. The same levels of security and confidentiality will also apply. 3.8.5 Adopted Persons Health Records 3.8.5.1 The records of adopted persons can only be placed under a new last name when an adoption order has been granted. Before an adoption order is granted, an alias may be used, but more commonly the birth names are used. 3.8.5.2 Depending on the circumstances of the adoption there may be a need to protect from disclosure any information about a third party. Care must be exercised when disclosing records of adopted patients because of the heightened risk of accidental disclosure. 3.8.5.3 It is important that any new records, if created, contain sufficient information to allow for a continuity of care. At present the patients GP will initiate any change of NHS number or identity if it was considered appropriate to do so, following the adoption. The Trust would then make changes to its own records in line with that initiated by the patient's GP. Page 12 of 26 3.8.6 Health Records of Transgender Patients 3.8.6.1 Patients considering or undergoing gender identity change may ask for changes to their name they are known by to be made and in most cases the Trust will agree to such a request. 3.8.6.2 A patient can request that their gender be changed in a record by a statutory declaration, but this does not give them the same rights as those that can be made by the Gender Recognition Act 2004. 3.8.6.3 The formal legal process (as defined in the Gender Recognition Act 2004) is that a Gender Reassignment Certificate is issued by a Gender Reassignment Panel. At this time a new NHS number can be issued and a new record can be created, if it is the wish of the patient. 3.8.6.4 Except in a limited set of circumstances it is an offence under the gender recognition act to disclose without consent information that would identify that a person has undergone a gender identity change. 3.8.6.5 The key to the successful management of records in these circumstances is to discuss with the patient their choices and agree what they wish to happen in respect to their health record. If a new health record is being created there is a need to identify which records are moved into the new record and to discuss how to link any records held in any other institutions with the new record. 4. Roles and Responsibilities 4.1 Chief Executive 4.1.1 As accountable officer the Chief Executive is responsible for the overall leadership and management of the Trust and its performance in terms of service provision, financial and corporate viability, ensuring that the Trust meets all its quality and safety, statutory and service obligations and for working closely with other partner organisations. The CEO delegates aspects of this responsibility to relevant Executive Directors according to their organisational portfolios. 4.2 Director of Transformation and Improvement 4.2.1 The Director of Transformation and Improvement is the appointed Executive Director with responsibility for Information Governance including records management and is the Trust Senior Information Risk Owner (SIRO). The SIRO is responsible for managing information risk in the Trust and will implement and lead the NHS Information Governance risk assessment and management processes within the Trust and advise the Board on the effectiveness of information risk management. 4.2.2 4.3 Caldicott Guardian 4.3.1 The Trust Caldicott Guardian is the Director of Nursing who has a particular responsibility for reflecting patients' interests regarding the use of patient identifiable information. The Trust Caldicott Guardian is responsible for ensuring patient identifiable information is shared in an appropriate and secure manner. The duties and responsibilities of the Trust Caldicott Guardian are outlined in the Trust Confidentiality and Data protection Policy. 4.3.2 Page 13 of 26 4.4 Trust Records Manager 4.4.1 The Trust Records Manager is responsible for ensuring that this policy is implemented and that the records management system and associated processes are developed, co-ordinated and monitored. The Trust Records Manager is also responsible for the overall development and maintenance of health records management practices and promoting compliance with this policy in such a way as to ensure the easy, appropriate and timely retrieval of patient information. 4.4.2 4.5 Local Managers 4.5.1 The responsibility for local records management is devolved to divisional, care group and department heads whom retain overall responsibility for the management of records generated by their activities, i.e. for ensuring that records created within their unit are managed in a way which meets the aims of the Trust's records management policy and associated procedures. 4.6 Clinical Leads and Matrons 4.6.1 Clinical leads in all professions have a responsibility to ensure clinical staff they manage who contribute to patient health records are adequately trained in record keeping and are aware of and adhere to the standards for record keeping outlined in this policy. 4.7 All Staff 4.7.1 Members of Staff who create, receive and use records have records management responsibilities. In particular all staff must ensure that they keep appropriate records of their work in the Trust and manage those records in keeping with this policy and with any guidance subsequently produced. Staff who make entries in medical records should do so in accordance with the clinical record keeping standards published in this policy. In addition Royal Colleges and other professional bodies publish record keeping guidance for clinical staff and it is the responsibility of clinical staff to ensure they keep up to date with and adhere to relevant legislation, case law and national guidance. Related Trust Policies 4.7.2 5. 5.1 The following Trust policies overlap with or relate to matters covered in this policy Information Governance Policy Data Protection and Confidentiality Policy Freedom of Information Policy Access to Records Policy Subject Access Policy IM&T Security Policy Incident Management Policy Patient Information and Corporate Identity Policy Web Publishing Policy 6. Communication Plan Page 14 of 26 6.1 The publication of this updated policy will be highlighted to staff via an article on the news section of `Staffnet', the Trust intranet. The article will draw attention to the key changes made to the previous policy version. 6.2 A copy of this policy will be available for staff to access via the policies section of Staffnet and links to the policy will also be provided within the records management section of the Information Governance pages of Staffnet. 6.3 Elements of record training and procedure form part of the annual training for information governance (now known as data security training) which forms part of the Trusts annual mandatory training requirement. 7. Process for Monitoring Compliance and Effectiveness 7.1 The purpose of monitoring is to provide assurance that the agreed approach is being followed � this ensures we get things right for patients, use resources well and protect our reputation. Our monitoring will therefore be proportionate, achievable and deal with specifics that can be assessed or measured. Key aspects of the procedural document that will be monitored: What aspects of compliance with the document will be monitored Compliance with Record handling best Practice and guidance What will be reviewed to evidence this How and how often will this be done Detail sample size (if applicable) Who will coordinate and report findings (1) Which group or report will receive findings Incidents reported with record related cause codes Medical records procedures for retrieval and tracking Medical Record Keeping Standards Sample or record movements recorded on Trust PAS Entries in sample of Trust inpatient medical records Ongoing monitoring carried out by local governance leads and Trust Records Manager Quarterly audit carried out by Medical Records Manager Annual Audit as part of Trust Clinical Audit programme. N/A Local governance leads and Trust Records Manager Serious breaches will be reported to the Information Governance Steering Group 25 records per quarter Medical Records Manager Information Governance Steering Group 100 records plus Audit managed by Trust Clinical Audit Manager and local Divisional audit leads Clinical Effectiveness Steering Group Where monitoring identifies deficiencies actions plans will be developed to address them. 8. Arrangements for Review of the Policy 8.1 This policy will be subject to formal review three years after publication unless significant changes in legislation or NHS guidance dictate an earlier review. Minor updates will be made as and when required. Page 15 of 26 8.2 If as a result of the full adoption of GDPR legislation into UK law on the 25th May 2018 a further amendment to this policy is required then this will be carried out. See para 1.2.3 above. 9. References Public Records Act (1958) Freedom of Information Act (2000) Data Protection Act (1998) General Data Protection Regulation Records Management Code of Practice for Health and Social Care 2016 Academy of Medical Royal Colleges' Standards for the clinical structure and content of patient records Chancellor's Code of Practice on the management of records issued under section 46 of the Freedom of Information Act (2000). The National Archives BS 10008 Electronic Information Management - Ensuring the authenticity and integrity of electronic information Appendices A. B. C. Record Creation and Filing Procedures Medical Record Keeping Generic Standards Categories of Records listed in NHS Retention Schedule Page 16 of 26 Appendix A to Records Management Policy User Guide to Record Creation Introduction 1. This guide primarily covers records created for non care purposes as the procedure for creating and filing patient records is part of the training given to users of the Patient Administration System. The key principles apply to all records however. 2. Although most records in the Trust are created and stored electronically some paper based record keeping systems are still in use. Most of the guidance provided in this document can be applied to both forms of records but where this is not the case users will need to exercise judgment when applying the guidance. 3. Common types of documents such as letters, meeting minutes, Job Descriptions etc should be always be created using the Trust Word Templates set up for these document types. When creating documents staff should take note of the guidance about document style contained in the Trust Patient Information and Corporate Identity Policy available on the Trust Intranet. 4. All records created in the Trust should be included in a record keeping filing system and be given a unique title or name to identify it. When creating records users need to consider the need for privacy markings and version control. The guidance set out in the following sections addresses these requirements and provides guidance in their application. Record Filing Systems 5. Records created in both electronic or paper form should be organised in some form of registered fling system so they can be easily located when needed and documents of a similar or linked nature are kept together. Filing systems can be created and organised using a variety of methods. Probably the most common method is a simple alphanumeric system whereby records are grouped together in folders that are given unique names. The folders are then organised/ordered in alphanumeric fashion in draws/cabinets (paper records) or within Trust HQ/Divisional/Care Group hard Drives (electronic records) 6. When designing and developing filing systems the following points should be considered: a. b. c. Retain control and continuity by restricting the number of staff who can create new folders in the system. Organise folders and sub folders in a logical manner that will make sense to those who need to access records within them. e.g. organised by function or teams. Give each folder a clear title that describes the contents within. e.g. `MeetingsDiv Board2009', `ComplaintsPatients200804to200906. Avoid names like `General', `Miscellaneous' or personal titles like `Jane's Folder'. (See next section for more details on file names) Within folders records are normally filed in chronological order by date of creation or receipt. It is good practice to clearly stamp on the front or all documents received the date of receipt. Folders in hard copy filing systems should be marked with the date the folder was opened and when closed the date of closure. When files are closed the date when the folder should be reviewed prior to disposal (usually at the end of the minimum retention period) should be added. In electronic filing systems these pieces of information can often be added to the metadata for the folders created. d. e. Page 17 of 26 f. g. A regular programme of reviews should be established to consider the need for closure and disposal of records/folders. The frequency of these reviews will largely depend on the size and growth rate of the filing system. A summary of the responsibilities, organisation and conventions used for each filing system should be set out in a document that is made available to all those who access the system. Folder and File Naming/Referencing Conventions 4. Names for folders and documents should be kept as short as possible whilst also being meaningful. Long file names create long file paths and links which increase the likelihood of error and are more difficult to remember. Avoid using personal names and codes and abbreviations that are not commonly understood. e.g. use `H&SCtteeTOR.doc' in preference to `Health_&_Safety_Comittee_Terms of_Reference.doc' 5. When creating sub folders and files within electronic filing systems there is no need to include in the file name descriptive information already contained in the parent folder as this will already form part of the filename/file path. e.g. use: not: `/.../DivBoard/agenda20100210' `/.../DivBoard/DivBoardagenda20100210 6. Avoid using spaces and underscores in file names. Some software packages have difficulty recognising file names with spaces. Use capital letters to delimit words. e.g. use `AuditMeetingsAgendas.doc' in preference to `Audit_Meetings_Agendas.doc' 7. When using a number in a file name always give it as a two digit number so that when it is displayed in the file directory in alphanumeric order it will be ranked in the correct order. Organised alphanumerically `ab2' will be listed after `ab10'. e.g. V01, V02, V03 etc not V1, V2, V3. 8. If using a date in the file name always state the date `back to front' and use four digit years, two digit months and two digit days: YYYYMMDD or YYYYMM or YYYY or YYYYYYYY. Writing dates in this way will present the records in chronological order in the file list with the latest record at the end of the list. e.g. use `20100201agenda.doc' not `1Feb2010Agenda.doc' 9. The elements of the file name should be ordered in the most appropriate way to retrieve the record. If records are retrieved by date the date element should appear first, if retrieved according to description then this should appear first. e.g. `20100201agenda.doc' (date retrieval) or `agenda20100201' (subject retrieval). Protective Marking of Documents 10. The NHS has agreed a scheme of classification using two privacy markings; Page 18 of 26 a. NHS CONFIDENTIAL. This classification should be used for paper and electronic documents containing personal identifiable clinical or NHS staff information and other sensitive information the compromise of which could lead to serious consequences for the Trust. The marking should be included at the top centre of every page of the document and documents so marked should be held and transported securely at all times. (The term NHS CONFIDENTIAL should never be used on correspondence to a patient.) b. NHS RESTRICTED. This classification should be used to mark all other sensitive information. Documents marked NHS RESTRICTED may also be endorsed with a suitable descriptor indicating the reason for the classification. A list of these descriptors is shown in the table below. The marking should be included at the top centre of every page of the document and documents so marked should be kept in lockable containers. 11. When classifying documents regard should be paid to the requirements of the Freedom of Information Act 2000. Careful consideration should be given to classifying documents that would be normally be published or disclosed on request.. Protective markings should wherever possible only be applied to documents that would be exempt from disclosure. Table 1 Categories of NHS RESTRICTED Documents Category Appointments Barred Board Commercial Contracts For Publication Management Personal Policy Proceedings Definition Concerning actual or potential appointments not yet announced Statutory prohibition on disclosure exists or disclosure would constitute contempt of court. Documents considered by an organisation's Board of Directors, initially in private. Where disclosure would be likely to damage a third party commercial undertaking's processes or affairs Concerning tenders Where it is planned that the information will be published at a future date. Concerning policy and planning affecting the interests of a groups of staff Concerning matters personal to the sender or recipient Issues of approach or direction on which the organisation needs to take decision. Information the subject of or concerned in a legal
Url: /Media/UHS-website-2019/Docs/Policies/Records-management-policy.pdf

Health and safety policy

Description: Health and Safety Policy Date Issued: 21/11/18 Review Date: 21/11/21 Document Type: Policy Version: 10.0 Contents Paragraph 1 2 3 4 5 6 7 8 9 Appendices Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F Appendix G Appendix H Appendix J Executive Summary / Policy Statement / Flowchart Scope and Purpose Definitions Details of Procedure to be followed Roles and Responsibilities Related Trust Policies Communication Plan Process for Monitoring Compliance/Effectiveness of this Policy Arrangements for Review of this Policy References Trade Unions and Professional Organisations Health and Safety Risk Assessment Form Risk Grading Matrix Fees for Intervention Health and Safety Self Auditing Non Patient Slips Trips and Falls First Aid Provision Display Screen Equipment Noise at Work Page 2 6 7 8 10 21 22 22 22 22 Page 24 25 27 30 34 38 41 43 44 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Page 1 of 48 Executive Summary The Health and Safety at Work etc. Act 1974 (HASAWA) places the duty on an employer to ensure, so far as is reasonably practicable, the health, safety and welfare of all employees and others who may be affected by its acts or omissions. This includes the provision and maintenance of safe plant, machinery, equipment and safe systems of work. Although the ultimate responsibility for compliance with the Act rests with employers, every employee also has a responsibility to ensure that no one is harmed or put at risk as a result of their acts or omissions during the course of their work. It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as reasonably practicable, that persons not his employment who may be affected thereby are not thereby exposed to risks to their health or safety (Section 3 HASAWA) Compliance with the Health and Safety at Work Act is a legal requirement. As such, an offence, committed under the Act would constitute a criminal offence and could lead to prosecution, resulting in a fine and/or a term of imprisonment. If the Trust commits an offence which is a material breach in the opinion of the Health & Safety Executive (HSE) inspector, or if there is or has been a contravention of health and safety law then a notice may be issued to the Trust. If a notice is issued or the inspector sees a material breach of the law, the trust will have to pay a fee. Reference Appendix D In addition to the Health and Safety at Work Act 1974, other Regulations, Approved Codes of Practice, Guidance Notes and Directives will apply. The Trust uses the Health & Safety Executive (HSE) model HSG 65 (see page 3) as a method of ensuring that the work of the Trust is conducted in a safe manner as far as is reasonably practicable. Page 2 of 48 HSG65: Managing for Health and Safety (Third Edition) Page 3 of 48 Health and Safety Policy - Flow Chart Page 4 of 48 UNIVERSITY HOSPITAL SOUTHAMPTON NHS FOUNDATION TRUST Health & Safety Policy Statement of Intent The University Hospital Southampton (UHS) NHS Foundation Trust Board of Directors and I are totally committed to ensuring the health, safety & wellbeing of all staff, patients, contractors and members of the public who are in any way affected by the undertaking of UHS’s activities. We will ensure the provision of appropriate resources, including staff, finance and equipment in a timely manner so as to conduct our activities in accordance with all statutory and regulatory requirements, seeking to exceed such requirements wherever reasonably practicable. We will develop and implement a range of policies and procedures in support of this statement and will ensure their effective communication to all staff and contractors. We will seek to embrace best practice from the wider healthcare community and will proactively seek out innovative and dynamic initiatives that will assist UHS in achieving the highest levels of safety performance and delivering the highest standards of clinical care, reviewing and amending our policies and procedures on a continuous basis. It will not be acceptable for any hazard, risk or safety incident to be ignored by any member of staff, or contractor, and we will ensure that systems and processes exist to identify and mitigate risk as well as for reporting, investigating and learning from incidents when they do occur. In delivering these aims, the Board expects and requires all staff and contractors to conduct themselves in a safe manner at all times and to engage with the Board in any and all safety initiatives that it identifies and implements in order to deliver continual safety improvement Paula Head Chief Executive University Hospital Southampton NHS Foundation Trust Page 5 of 48 1 Scope and Purpose This policy sets out the principles and arrangements by which University Hospital Southampton (UHS) Foundation Trust base both their commitment to Health and Safety and their compliance with legislation. The policy forms part of the UHS’s overall approach to staff and patient safety as set out in the Health and Safety and Patient Safety Strategies. This policy applies to all staff employed by the Trust, either directly or indirectly, and to any other person or organisation which uses Trust services or premises for any purpose. It will also apply to bank, temporary staff, volunteers, young workers, staff working from home and contractors working on Trust business. The principles of this policy shall apply to all Trust work activities, regardless of who has or is supplying or providing them. The aims of this policy are to: o Outline the requirements of Health & Safety Regulations, Health & Safety Guidance and Approved Codes of Practise that apply to the Trust. o To inform managers and staff as to their roles and responsibilities with respect to these. o To demonstrate the Trust’s commitment to reducing accidents and incidents causing ill-health as well as other environmental hazards and risks in the workplace o To set out the organisation’s arrangements for Health and Safety in accordance with HSG 65 o To set out the organisation’s training requirements for Health & Safety The objectives of this policy are to: o To ensure that the Trust has a proactive management system in place to enable it to comply with all relevant statutory health and safety legislation. o To reduce the numbers of accidents and incidents which cause harm o To prevent foreseeable accidents or incidents so far as is reasonably practicable by undertaking suitable and sufficient risk assessments o To demonstrate how UHS complies with its Statutory Health and Safety compliance against Legislation, Regulations, Approved Code of Practice (ACOPs), best practice, etc o To prevent reoccurrence of adverse events as far as is reasonably practicable o To ensure compliance with relevant NHS Litigation Authority standards, Care Quality Commission (CQC) Essential Standards of Quality and Safety and other Department of Health (DoH) requirements such as Health Technical Memorandum (HTM) or Health Building Note (HBN) where practicable. o To ensure that contractors recognise their duty of care to the Trust and their employees and will be bound by their terms of contract to comply with The Health and Safety at Work Act, subordinate regulations and the Trust Consultant’s and Contractor’s Handbook’ Page 6 of 48 2 Definitions o Reasonably Practicable: means that you have to take action to control the health and safety risks in your workplace except where the cost (in terms of time and effort as well as money) of doing so is "grossly disproportionate" to the reduction in the risk. o Competency: knowledge, skills, qualifications, training, experience or ability to undertake a particular job, the term ‘competent person’ also refers to the roles and responsibilities of those managing health & safety matters o Employee: means any member of staff who holds a contract of employment directly with the Trust o Contractors: persons or agencies engaged by the Trust to provide a specific service. This includes bank staff, agency staff, staff employed by other Trusts, organisations and agencies occupying Trust premises o Hazard: a hazard is anything with the potential to cause harm e.g. chemicals, electricity, working at height, noise etc. o Risk: the likelihood that the hazard will actually cause harm, injury or damage; it also considers the consequences, extent and outcome of a hazardous event occurring o Suitable and Sufficient: that all significant hazards have been identified, the risks have been properly evaluated considering likelihood and severity of harm, measures necessary to achieve acceptable levels of risk have been identified, actions have been prioritised to reduce risks, the assessment will be valid for some time, actual conditions and events likely to occur have been considered during the assessment, everyone who may be harmed has been considered o Young person: is anyone under eighteen years of age (young people). The law on working time defines a young worker as being below 18 years of age and above the Minimum School Leaving Age. o Approved Code of Practice (ACOPs): Approved Codes of Practice give practical guidance on compliance. o Volunteer: A person carrying out work activities within the Trust, for the benefit of staff, patients and/or visitors without reward in cash or kind, and on behalf of one of the Trust’s recognised volunteer groups. Reasonable expenses received from the recognised volunteer group will not affect a volunteer’s status. Page 7 of 48 3 Details of Procedure to be followed 3.1 Risk Assessment The law places an ‘absolute duty’ on employers to carry out risk assessments, which should be a record of:  identified hazards arising from or in connection with the work;  who will be affected by the hazards;  the control measures in place or proposed control measures;  evaluation of the risk  review date Health & Safety Risk assessments are required to be undertaken for tasks/ environments/ situations identified as presenting a significant risk of injury either to Trust staff, visitors or patients. Risk assessments should be completed using the Trust’s Generic Health & Safety Risk Assessment Form Appendix B, and scored according to the guidance in Appendix C, and these should be monitored and reviewed in the following circumstances:  whenever there is a significant change e.g. staff, environment or equipment;  after an accident or ‘near miss’;  after non compliance identified through audits and inspection programmes  at least annually Risks that cannot be managed and actioned locally should be escalated to the risk register following guidance contained in the Risk Management Policy and Procedures Health & Safety Risks relating to the following hazards, should be identified and recorded using the specialised risk assessment forms contained in the related Trust policies, listed under section 5 of this policy:  Ionising or Non-Ionising radiation including lasers and other intense light sources  Magnetic Resonance (MR) fields  COSHH,  Visual Display Unit use,  Moving and Handling of patients or equipment  Stress 3.2 Health and Safety Training Details of training course dates and registration information, Statutory and Mandatory Training, Corporate Induction and refresher training are advertised on the Virtual Learning Environment (VLE) and details of training requirements are outlined in the Training Needs Analysis. Specific training including local induction related to the particular work activity must be provided by managers. Where the use of specialist equipment or work practices is required, suitable training will be arranged by the relevant manager. A range of Health and Safety training courses is provided for managers and staff by the Health & Safety Manager/Advisor/Moving & Handling Adviser. These include:  H&S Lead coordinators  H&S Risk Assessments  Control of substance hazardous to health (COSHH)  Moving and Handling clinical handling leads  Moving and Handling load handling leads Page 8 of 48 3.3 Auditing Departments will carry out a health and safety self-audit annually, following the process outlined in Appendix E. Once self audits are submitted to the Health and Safety team, the team will summarise results and report to the Corporate Health and Safety Committee and QGSG. Self audit returns will be followed up in Health and Safety Tours in departments, and in incident investigations and inspections. 3.4 Non Patient Slips Trips and Falls Non Patient Slips Trips and Falls will be controlled as outlined in Appendix F. 3.5 Provision for Emergencies Planning for fire emergencies is the responsibility of the Fire Safety Advisor and controlled as outlined in the Fire Safety Management Policy. Spillages of hazardous substances are managed according to the COSHH policy Planning and provision of first aid is managed as outlined in Appendix G to this policy 3.6 Incident Reporting. All staff are expected to report accidents and incidents using the “Safeguard” incident reporting system, from where appropriate managers will investigate and take appropriate remedial actions. Incidents reportable to the Health and Safety Executive under the RIDDOR Regulations must be brought to the attention of the Health and Safety Team, who will investigate and report appropriately. Guidance on which incidents are reportable under RIDDOR is available on StaffNet at http://staffnet/Workinghere/Staffessentials/Staffhealthandsafety/RIDDOR.aspx Page 9 of 48 4 Roles and Responsibilities 4.1 Chief Executive The Chief Executive (CEO) has overall responsibility to provide a safe environment throughout the Trust, ensuring compliance with the requirements of The Health and Safety at Work etc, Act 1974, all subordinate Health and Safety Regulations, ACOPs & Guidance, the requirements of this policy and any subsequent amendments to these. The CEO has overall accountability for the safety of any member of staff, patient, visitor, contractor, and others, whilst they are on those Trust premises under their control. The CEO is also responsible for the health and safety of other stakeholders and neighbours who may be affected by the work and undertakings of the Trust. The CEO has overall responsibility to make arrangements to ensure:  That the requirements of the Trust’s Health and Safety Policy are organised, planned and implemented  That the Trust Board is informed of relevant health and safety matters affecting the Trust, its employees, contractors, patients, neighbours, other stakeholders and the wider public  That suitable and sufficient resources and support are provided for the training and development of Trust staff in all relevant health and safety matters  That monitoring, measuring, reviewing and auditing of the Trust’s health and safety performance is undertaken  That the Trust's Health and Safety plans and performance are discussed at Board level 4.2 Director of Nursing and Organisational Development The Director of Nursing and Organisational Development, in liaison with the Medical Director, has delegated executive responsibility for health and safety in particular for:  Informing the Board on all relevant health & safety management issues, including alerting the Board to the requirements of this policy and any actual or potential breaches of Health and Safety Legislation  Ensuring, through the Quality Governance Committee structure, that relevant persons are consulted with and informed of any changes that may substantially affect their health and safety e.g. in procedures, equipment or ways of working  Ensuring clear lines of accountability throughout the organisation for the management of health and safety and that all staff groups are represented in the Quality Governance Committee structure  Ensuring that staff are provided with information on the likely risks and dangers arising from Trust work and activity, introduce measures to reduce or get rid of those risks and inform staff as to what they need to do if they have to deal with a risk or danger  Putting arrangements in place to get competent people to help them satisfy health and safety legislative requirements  Ensuring co-ordination and co-operation on health and safety matters between the Trust, its neighbours, contractors and any other relevant stakeholder  Ensuring that suitable plans are in place to manage health and safety Page 10 of 48  Ensuring that adverse health and safety consequences of introducing new technology, equipment or procedures and ways of working are mitigated so far as is reasonably practicable 4.3 Executive and non-Executive Directors All Executive and Non Executive Directors have corporate responsibility to provide a safe working environment and shall ensure adequate arrangements and resources are provided to implement the requirements of this policy, all relevant Safety Regulations and any associated procedures and safe systems of work; and apply this within their respective areas of responsibility. They ensure that health and safety arrangements are adequately resourced and that they obtain competent advice and that they review reports, performance and action plans to ensure compliance. They recognise that it is a criminal offence for a company to fail in any of the duties imposed by the Act, and an accident may give rise to civil liability as well. Directors can be prosecuted for the criminal offence as well as the organisation. 4.4 Director of Quality  Is the operational lead for health and safety, reporting to the Director of Nursing and Organisational Development  Deputise and carry out the duties of the Director of Nursing and Organisational Development in their absence 4.5 Divisional Clinical Directors / Divisional Directors of Operations / Divisional Heads of Nursing / Heads of Departments / Senior Managers/ Managers / Supervisors The following is not an exhaustive list but in general terms, managers at all levels must ensure:  That they have or undertake to obtain such information, instruction and training to enable them to lead on matters of health and safety commensurate with their respective role or position  That all risk assessments are carried out and documented by persons competent to undertake such assessments following Trust policy  That risk assessments are systematically reviewed and where necessary ensure that suitable protocols, plans and procedures are further updated or developed to provide adequate controls and safety precautions  That they support local managers and work with lead risk assessors, staff and staff representatives to provide suitable and sufficient equipment which is serviced and maintained and put systems and procedures in place to control and safely manage any identified risks  That they and local managers discuss and disseminate Trust safety policies and implement the requirements of those respective policies to ensure cooperation and communication by all  That they make adequate funding available to provide any necessary equipment, procedures and ongoing training and supervision to meet the requirements of the Health and Safety Policy and/or where a risk assessment has identified such control measures as being necessary Page 11 of 48  That health and safety performance standards and objectives are set for their managers and those under their supervision  That they manage the timely reporting of accidents and incidents in accordance with the Incident Reporting, Analysis, Investigation and Management Policy  That investigations are undertaken, the Incident Reporting Procedure is followed and that the Significant Incident Requiring Investigation (SIRI) and Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) procedures are followed, where necessary  That they intervene to prevent poor Health and Safety practice or procedures, as needs be  That they ensure any member of staff who ignores or deliberately fails to discharge their responsibilities for health and safety has been reprimanded or disciplined as per the Trust Disciplinary procedure and HR Policies  That they provide safe access and egress to Trust buildings, wards, departments and areas they are responsible for and provide safe means of transport and methods of movement of patients and staff; particularly when evacuation is required.  That they ensure the managers, supervisors and staff under their control or responsibility attend the appropriate training and health surveillance, including induction training, local induction and familiarisation, mandatory and statutory training; health surveillance for dermatitis, latex allergy, upper limb disorder, stress or occupational asthma, and any other training or health surveillance that is deemed necessary  That they maintain a system of regular inspections and audits to determine the degree of compliance with both Trust and local policies & procedures and take appropriate remedial action to address any areas of non-compliance  That they ensure that all staff under their control or supervision are afforded the same level of protection  That health and safety matters are discussed and incorporated as necessary into staff’s job descriptions, appraisals, team meetings and escalated through the local Governance Committee structure. 4.6 Director of Estates & Capital Development The Director of Estates and Capital Development is responsible for ensuring that the H&S Policy is implemented throughout the Estates and Capital Development (E&CD) department, together with its monitoring and updating. The Director of E&CD will be assisted in this by the members of the Estates Management Team, namely: the Deputy Director of E&CD, Head of Estates Maintenance; the Head of Estate Projects; the Head of Compliance; the Infrastructure Services Manager, the Estates Health & Safety Manager, the Head of Clinical Engineering, and Building Maintenance Managers. The Director of E&CD is also responsible for ensuring that the H&S Policy is applied to all work undertaken by design consultants, cost advisers, contractors and subcontractors and suppliers, as is appropriate. 4.7 Health & Safety Manager  Ensures that the Trust has a robust Health & Safety Policy outlining the commitment of the CEO and the Trust Board, to ensuring the Health & Safety of Page 12 of 48 all persons who either work for, or come into contact with, the Trust’s estates and activities.  To liaise effectively with the Health & Safety Executive (HSE), and other safety related external agencies, on behalf of the Trust  To regularly monitor and review all existing Trust wide policies relating to H&S and ensure that all H&S policies are readily available to all staff, that changes are effectively communicated and that they are robustly implemented.  Develop H&S training and ensure implementation strategies facilitate compliance and contribute to the Trust broader Education Strategy.  Analyse H&S related Trust wide adverse H&S events, ensuring appropriate investigation, production of detailed reports, and reporting as appropriate. To analyse health & safety data contained on the system, producing reports as necessary for relevant groups, identifying trends and recommending consequential change/s as required.  Produce an Annual Health & Safety Report for the Board setting out the achievements and shortcomings of the previous 12 months and making recommendations to bring about future improvements  To manage and provide leadership for the Trust Manual Handling Advisor and the Health and Safety Advisor.  Chair the Corporate Health & Safety Committee  Provide Health and Safety Reports to the Trust Board as required  Act as the nominated ‘competent person’ for the Trust as required by law, including providing input to planning of refurbishments, equipment sourcing and implementation, and other work likely to affect the health, safety and welfare of staff, visitors and patients. 4.8 Health & Safety Advisor  Will assist in the development, production and delivery of strategies that procures Trust wide compliance regarding health & safety, with statutory national and local regulations, Department of Health Directives and Trust Policies.  Will prepare and deliver as required senior management reports to various forums where health & safety is discussed.  Take part in investigations of accidents, near misses and other incidents and provide Health and Safety perspective to recommendations for remedial and preventive actions.  Working with the colleagues from the health & safety team to put in place an effective system in order to audit divisional compliance with the Trust Health & Safety strategies, producing reports for that identify both compliant and noncompliant areas.  Will coordinate visits, inspections by the Health & Safety Executive and the provision of such documents that may be requested by an inspector regarding the Trusts statutory duty.  Will provide expert advice and guidance on health and safety policy, guidance and assessment. Page 13 of 48  Work with colleagues in identification of appropriate health & safety training, strategies and contribute to the Trust health & safety education strategy..  Will chair the Health & Safety Leads meetings. 4.9 Trust Moving & Handling Advisor  Acts as the principle advisor for all Trust moving and handling activities by providing moving and handling information, expertise and advice within the Trust on the suitability of moving and handling aids and appropriate training for both staff and patients in order to ensure Trust wide compliance with statutory national and local moving and handling regulations  Undertakes moving and handling audits across the Trust alongside the Trust Health and Safety Team in order to put in place an effective system to audit compliance with the Trust moving and handling strategies. To provide a detailed report of any findings to Senior Managers informing of appropriate actions  Supports Nominated Moving and Handling Leads in providing moving and handling information, expertise and advice to their areas by chairing bi-monthly meetings in order to promote and adapt safer moving and handling practice in areas where moving and handling is challenging. 4.10 Radiation Protection Advisor The Radiation Protection Adviser is a suitably qualified and competent person appointed under the Ionising Radiations Regulations 1999, and is responsible for:  Providing advice and guidance in the safe management and use of radionuclide and radiation generating equipment and the safe storage and disposal of any contaminated waste  Advising the Trust regarding arrangements to undertake and document risk assessments, procedures and systems of work relating to radiation generating equipment and the use of radioactive materials  Providing reports for committees and advising on the updating of relevant Trust Policies  Advising on the investigation of incidents involving ionising radiation and on planning for major incidents involving radioactive material 4.11 Laser Protection Advisor The Laser Protection Adviser must be a suitably qualified, competent person appointed according to the Guidance on the Safe Use of Lasers, Intense Light Source Systems and Light Emitting Diodes (LED’s) in Medical, Surgical, Dental and Aesthetic Practices (MHRA 2015) and is responsible for:  Providing advice and guidance in the safe management and use of lasers and associated equipment  Advising the Trust regarding arrangements to undertake and document risk assessments relating to lasers  Providing reports for committees and updating relevant Trust Policies 4.12 Magnetic Resonance Safety Expert The MHRA Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use 2015 (v4.2) state that the MR Safety Expert is a designated professional with Page 14 of 48 adequate training, knowledge and experience of MRI equipment, its uses and associated requirements. They should:  Develop safe operating procedures and policies and risk management solutions to ensure MR safety for patients, staff and visitors.  Develop an appropriate framework for managing safety in relation to MR, including effective review processes and reporting mechanisms within the Trust.  Prepare and periodically review the MRI local rules for the MRI units across the Trust.  Provide reports regarding MR safety developments to Trust committees and contribute to/update relevant Trust policies (including the Policy for the Safe Use of MRI).  Advise on the implementation of national and international MR guidelines and legislation within the Trust.  Carry out MR safety audits and risk assessments to assess and ensure compliance with national guidelines and good safe practice and to monitor the effectiveness of safety procedures.  Advise on the planning and the configuration of MR facilities in order to promote safety, working with, and recognising the experience of, the system vendor installation team.  Provide patient (and staff/visitor) specific advice with regard to MRI safety, such as that concerning implants (for example).  Assist with the investigation of incidents relating to MR equipment. 4.13 Fire Safety Advisor The Fire Safety Advisor (FSA) is responsible for ensuring the development and implementation of the Fire Safety Management Policy ensuring that safe systems and processes are in place for the continuous effective management of fire safety risks as required by statutory, national, local regulations, department of health directives and related trust policies. The FSA will work with the Fire Manager to put in place an effective system in order to audit divisional compliance with the Trust Fire Management Policy and to analyse fire related Trust wide adverse events producing reports as necessary for relevant groups, identifying trends and implementing change as required. 4.14 Occupational Health The Occupational Health Service are responsible for the assessment and enhancement of fitness for work, for advising about control of health risks in the workplace, and for leading staff health and wellbeing, specifically by providing:  co-ordination and provision of staff health and wellbeing support/services  pre-placement screening  immunisations against infectious diseases  management of sharps and contamination incidents  health surveillance  staff support and counselling  advice about adjustments to work on health grounds Page 15 of 48  rehabilitation back to work after illness  special advice to managers on generic risk assessments  advice to managers on individual risk assessments (taking account of individual susceptibility due to pregnancy or health problems)  health promotion and wellbeing advice  regular feedback to Trust Board on work-related ill health The Occupational Health service is impartial and confidential, aiming to give objective advice to both employees and managers. Employees’ OH records are held securely and are not accessible to anyone outside the OH service. Information about individuals will not be passed to anyone without that individual’s consent. 4.15 HR Department The Director of Human Resources has delegated responsibility for ensuring a robust strategic approach is adopted addressing issues of employee’s health, safety and wellbeing. This includes:  The development and implementation of a series of Human Resource policies which are compliant with health and safety legislation and which reflect the support mechanisms in place to assist and support employees health, safety and well-being.  The commissioning and development of appropriate staff support services. HR Teams are responsible for providing awareness sessions for staff and coaching for managers on the implementation of policies and HR best practice. 4.16 Security Manager The Security Manager for the Trust is the appointed Local Security Management Specialist (LSMS) and will undertake the duties of an LSMS in accordance with Secretary of State Directions to health bodies on measures to tackle violence and general security management measures, and any subsequent advice or guidance issued by the NHS SMS. This includes:  To ensure that all NHS security management work is carried out within a professional and ethical framework developed and provided by the NHS Security Management Specialist (SMS).  To ensure that an inclusive approach to security management work is taken, involving both internal and external NHS stakeholders where appropriate and necessary  To report to the health body’s Chief Operations Officer on security management work locally  To lead on day-to-day work in their health body to tackle violence against staff and professionals in accordance with the NHS SMS national framework and guidance.  Ensure appropriate steps are taken to create a pro-security culture within the health body and amongst contractors so that staff and patients accept responsibility for this issue and ensure that any security incidents or breaches that occur are detected and reported  Attend the health body’s risk management, health and safety and audit committee meetings and ensure appropriate links are made with the health body’s risk assessment process, including the health body’s health and safety Page 16 of 48 representatives, so that security-related issues are an integral part of that process  Participate in the health body’s induction programme for new staff and develop and deliver security awareness sessions for stakeholders  Ensure lessons learnt from security incidents and breaches are fed into risk analysis, both locally and nationally, so that appropriate preventative measures can be developed  Ensure security incidents are reported using the NHS SMS reporting system, ensuring that investigations take place where appropriate, risks are assessed and preventative measures are developed (this will include participation in local and national risk identification projects)  Ensure security incidents and breaches are investigated in a fair, objective and professional manner so that the appropriate sanctions are applied and measures put in place to prevent recurrence  Ensure consideration is given to cases not progressed by the police or CPS and, where appropriate, work is undertaken with the NHS SMS Legal Protection Unit and the health body, and redress is sought where appropriate. 4.17 Infection Prevention Team The Infection Prevention Team are responsible for providing the Trust with advice and guidance on infection prevention and control matters, for supporting staff in the implementation of infection prevention policies, and assisting with risk assessment where complex decisions are required. The Infection Prevention Team are also responsible for escalating concerns to the Quality Governance Steering Group and the Corporate Health & Safety Committee (CHSC). 4.18 Litigation and Insurance Services Department The Litigation and Insurance Services Department is responsible for:  Managing all clinical negligence and personal injury (extending to contract challenges where required) claims ethically and cost effectively on behalf of the Trust. This should be in accordance with Trust policy and procedures, based on NHSLA and NHS Executive (NHSE) guidelines. Ensuring the Trust complies with its statutory legal responsibilities in relation to the management of all claims.  In accordance with the Pre-Action Protocol and Civil Procedure Rules undertake all pre-action investigations; communicate with clinical and non-clinical staff to obtain evidence in the form of statements, internal expert medical and nonmedical opinion and documentation in the context of allegations of negligence or breach of statutory duty, consider the complexities of each case and perform a preliminary analysis of each individual claim to form a reasoned opinion on liability and quantum on the basis of evidence obtained.  In respect of the National Health Service Litigation Authority (NHSLA), Clinical Negligence Scheme for Trusts (CNST), Liabilities to Third Parties Scheme (LTPS) and Properties Expenses Scheme (PES), liaise and negotiate with insurers and external solicitors (both claimant and Trust) on claims covered under the various NHSLA compensation schemes.  Provide regular reports via the Health & Safety Report reporting on a quarterly an annual basis identifying newly reported claims and reporting on lessons learned, themes and actions taken Page 17 of 48  Attend Trust committees as required and to provide ad hoc general healthcare related advice.  Ensure that the Trust’s insurance provision is both adequate and maintained on annual basis. 4.19 National Institute for Health Research (NIHR) Wellcome Trust Clinical Research Facility (WTCRF) is responsible for:  Ensuring that all research studies, including clinical and non-clinical interventions conducted within its facilities/ in the community by staff/visiting researchers are following Trust policies. The facilities include clinical, non-clinical and research laboratory areas.  Reporting health & safety concerns rising from the management of research that are serious and impact on business to the Research & Development (R&D).  Directly reporting to the Trust’s relevant governance meeting/s as required by those meetings (currently quarterly audits).  Keeping and maintaining the WTCRF risk register and reporting directly to the Trust. Biomedical Research Unit (BRU) is responsible for:  Ensuring that all research studies, including clinical and non-clinical interventions conducted within its facilities/ in the community by staff/visiting researchers are following Trust policies. The facilities include clinical, non-clinical and research laboratory areas.  Reporting health & safety concerns rising from the management of research that are serious and impact on business to the R&D Department.  Directly reporting to the Trust’s relevant governance meeting/s as required by those meetings (currently quarterly audits).  Keeping and maintaining the BRU risk register and reporting directly to the Trust. 4.20 Employees All employees have a responsibility to:  Take reasonable care of their own health and safety and that of others who may be affected by what they do or do not do  Co-operate with the Trust on Health and Safety issues  Not interfere with or misuse anything provided for their or other’s health, safety or welfare  Use any equipment, Personnel Protection Equipment (PPE), and procedures provided by the Trust, take reasonable care of it and to report any accidents, defects, damage, unsafe acts or conditions, near misses, or loss as soon as reasonably possible.  Be aware that willfully or intentionally interfering with or misusing equipment, procedures or safe systems of work will be subject to disciplinary action (See Trust Policy on Disciplinary procedures)  Read and understand the requirements of the Trust’s health and safety policies, other relevant safety procedures, risk assessments, local rules etc, and carry out work in accordance with these requirements Page 18 of 48  Ensure they report immediately any ill health, stress or other medical condition which may be work related or affect their ability to work safely  Ensure they attend any Health and Safety induction or training courses provided for them. 4.21 Trade Union and Staff-side Representatives Trade Union and Staff-side Health and Safety Representatives have the following responsibilities:  To represent Trust employees in consultation and co-operation with managers with a view to developing measures to ensure the health and safety at work of employees  To highlight potential hazards, risks and dangerous occurrences in the workplace (whether or not they are drawn to their attention by employees they represent) and to be proactive by assisting in preventing accidents and adverse incidents in the workplace  To investigate complaints by any employee whom they represent relating to that employee’s health, safety or welfare at work  To make representations to Trust management on any matter affecting the health and safety of employees in the workplace  To assist in Health and Safety audits when requested  To attend and contribute towards Health and Safety Committee meetings Recognised Trade Unions and Staff Organisations for the Trust are listed in Appendix A. It is the responsibility of each of the accredited Trades Unions and the Joint Staff Committee to inform the Corporate Health & Safety Committee, in writing, of their current health and safety representatives and any subsequent changes 4.22 Estates and Capital Developments The Estates Team are responsible for the management of the Estate which covers both new construction works and maintenance of existing assets. Activities related to working at height, roof work, use of cranes, internal flooring, external grounds & gardens and routine inspections, fall within the scope of areas highlighted in this policy. Estates and Capital Developments oversee construction work activity which is defined in detail in Regulation 2(1) of the Construction (Design and Management) Regulations 2015. 4.23 Serco (Cleaning and catering contractors) Serco, our cleaning and catering contractor, has a Health and Safety Policy which their employees must all adhere to. This policy includes the statement below: ‘ “Our work is never so urgent or important that we cannot take time to do it safely and with respect for the environment. Wherever we work, we are committed to the promotion of wellbeing and the prevention of injury, ill health and pollution including seeking to reduce the amount of carbon produced and the sustainable use of global resources, while reducing our waste through good waste management and recycling.” Page 19 of 48 4.24 All Contractors employed by the Trust All contractors and sub-contractors under the control of or employed directly or indirectly by the Trust must undertake their work in a safe manner. This work must be undertaken in accordance with statutory safety requirements and the Trust’s policies and procedures. Contractors and sub-contractors must fully co-operate with the guidance set out in the document Consultant’s and Contractor’s Handbook’ part of the contract documents issued prior to the commencement of any works. They must ensure that:  They and other self-employed persons (engaged on Trust business) assess and document the risks of their work and undertakings and make provision to protect themselves and others in respect of their own work activities.  That they are competent and authorised to carry out the required work and they have the supporting documentation to evidence this through risk assessments, safety plans and/or method statements, permits to work, etc  That all their employees (& sub-contractors) are appropriately informed, instructed and trained in health, safety and welfare related matters pertaining to their own and Trust work activities  That reasonable steps are taken to ensure co-operation and communication between all contractors and Trust staff and other relevant persons  That they report significant accidents and incidents to the Trust when undertaking their work and incidents that fall within Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR)1995 which occur as a result of the contractor’s undertakings  That they provide safe access to and from their workplace for their own staff and all others affected by their undertakings and put in place provisions to deal with a fire and do nothing to compromise the fire systems and procedures already in place within the Trust 4.25 Volunteers and Charitable organisations Even though charity and voluntary workers generously give their time, work and expertise to the Trust, these people are regarded as honorary employees in the eyes of the law and as such are bound and protected by the same health and safety conditions as all other Trust staff. Charity or voluntary workers or any Trust manager or representative responsible for them must ensure that risk assessments of their activities are undertaken and the identified risks are managed 4.26 Health & Safety Management Framework  Quality Governance Steering Group (QGSG) The delegated committee for overseeing the compliance with this Policy and the operation of the Corporate Health and Safety Committee is the Quality Governance Steering Group which is accountable to the Trust Executive Committee and the Trust Board.  Corporate Health and Safety Committee In accordance with the Health and Safety at Work Act 1974, the Safety Representatives and Safety Committees Regulations 1977 and at the request of staff representatives, the Trust has a Corporate Health and Safety Committee which acts in accordance with the Approved Code of Practice as per the requirements of these Regulations. Page 20 of 48  The Corporate Health and Safety Committee sits within the Trust’s Quality Governance & Risk Committee structure and is a key part of the arrangements for managing health and safety issues in the Trust. The details of the functions and Terms of Reference of the Committee and the means of making contact with its members can be found on the Staffnet http://staffnet/WorkingHere/Staffhealthandsafety/Healthandsafetycommittees/Cor porateHealthandSafetyCommittee/CorporateHealthandSafetyCommittee.aspx 5 Related Trust Policies  Patient Safety Strategy  Risk Management Policy and Procedures  Incident Reporting, Analysis, Investigation and Management Policy  Fire Safety Management Policy  Moving and Handling of Loads Policy  Control of Substances Hazardous to Health (COSHH) Policy  Security Policy  Sharps Safety Policy  Lone Worker Policy  Patient Falls Policy – The Management and Prevention of falls  Waste Management Policy  Non-Ionising Radiations, Policy for the Safe Use of  Safe Use of Ionising Radiations Policy  Magnetic Resonance Imaging, Policy for the Safe Use of  All Occupational Health policies relating to Health and Safety  All other Estates policies and procedures relating to Health and Safety  Whistle Blowing Policy Page 21 of 48 6 Communication Plan 6.1 The Trust Health and Safety Policy will be displayed on the Staffnet. 6.2 The Trust Health and Safety Manager/Adviser will provide updated information to nominated care group leads at bi-monthly meetings. . 6.3 The nominated care group leads will disseminate health and safety information through departmental co-ordinators as appropriate and ensure that this information is passed onto all staff. 6.4 Health and Safety is included in the Trust Corporate induction programme held monthly for all new staff. 7 Process for Monitoring Compliance/Effectiveness Key aspects of the procedural document that will be monitored: Element of Policy to be monitored Completion by wards and departments of the H&S self audit tool Monitoring the requirement to undertake appropriate risk assessments Lead Tool/Method Frequency Who will Where results undertake will be reported The completed audit tools and action plans /completed Health & Safety Tour reports Risk assessments Weekly via Health & Safety Tours and on receipt of completed Health & Safety audit tools each March. During inspections, incident investigations and tours All Health and Safety audited areas annually During inspections, incident investigations and tours Corporate Health and Safety Team Health & Safety Team The Corporate Health and Safety Committee The Corporate Health and Safety Committee Where monitoring identifies deficiencies actions plans will be developed to address them. 8 Arrangements for Review of the Policy This policy will be reviewed and validated before the end of September 2019 or sooner if new evidence demonstrates need for a change to current practice. 9 References  The Health and Safety at Work etc Act 1974  Management of Health and Safety at Work Regulations 1999 (2002)  The Health and Safety Executive (HSE) http://www.hse.gov.uk/  Corporate Health and Safety Committee Terms of Reference Page 22 of 48  Safety Representatives and Safety Committees Regulations 1977 (as amended) and Health and Safety (Consultation with Employees) Regulations 1996 (as amended)  HSE-Slips trips and falls in the health service http://www.hse.gov.uk/pubns/hsis2.pdf  HSE-Preventing slips and trips at work http://www.hse.gov.uk/pubns/indg225.pdf  HSE-What causes slips and trips http://www.hse.gov.uk/slips/causes.htm  HSE-‘Falls from Height http://www.hse.gov.uk/falls/  HSE-‘Watch Your Step Campaign http://www.hse.gov.uk/watchyourstep/  HSE- ‘Slips Assessment Tool’ http://www.hse.gov.uk/slips/sat/index.htm Page 23 of 48 Trust Health and Safety Policy Appendix A – Trade Unions and Professional Organisations Appendix A The Trade Unions and Professional Organisations listed below are formally recognised by the Trust as being able to represent their members on individual issues, and for collective bargaining purposes: Association of Clinical Biochemists British Association of Occupational Therapists British Dental Association British Dietetic Association British Medical Association British Orthoptic Society Chartered Society of Physiotherapy Federation of Clinical Scientists General and Municipal Boilermakers Union Royal College of Midwives Royal College of Nursing Society of Chiropodists and Podiatrists Society of Radiographers Union of Construction, Allied Trades and Technicians UNISON UNITE THE UNION ACB BAOT BDA B Diet A BMA BOS CSP FCS GMB RCM RCN SOCP SoR UCATT UNISON UNITE Page 24 of 48 Trust Health and Safety Policy Appendix B – Generic Risk Assessment Form Appendix B - Generic Health & Saf
Url: /Media/UHS-website-2019/Docs/Policies/Health-and-safety-policy.pdf

Your personal data and your rights - patient information

Description: As part of your care at University Hospital Southampton we will need to collect information about you. This data is vital to us providing high quality care, conducting the best research and doing it in the most efficient way possible.
Url: /Media/UHS-website-2019/Patientinformation/Visitinghospital/Your-personal-data-and-your-rights.pdf

Diarrhoea and/or vomiting outbreak - patient information

Description: This factsheet contains information regarding an outbreak of diarrhoea and/or vomiting within the hospital.
Url: /Media/UHS-website-2019/Patientinformation/Visitinghospital/Diarrhoea-andor-vomiting-outbreak-1239-PIL.pdf

Falling from hospital property

Description: Hospitals have a duty to prevent incapacitated patients from hurting themselves.
Url: /HealthProfessionals/Clinical-law-updates/Falling-from-hospital-property.aspx

Papers Trust Board - 29 November 2022

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