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Same-sex-accommodation-policy

Description: Same Sex Accommodation Policy Date Issued: 13 March 2018 Review Date: 24 January 2021 Document Type: Policy Version:
Url: /Media/UHS-website-2019/Docs/For-patients/same-sex-accommodation-policy.pdf

Data protection and confidentiality policy

Description: University Hospitals Southampton NHS Foundation Trust needs to collect and use information about people with whom it deals in order to
Url: /Media/UHS-website-2019/Docs/Policies/Data-protection-and-confidentiality-policy.pdf

Annual ward staffing review January 2025

Description: [5.15] Report to the Trust Board of Directors, 7th January 2025 Title: Ward Staffing Nursing Establishment Review July 2024 – October 2024 Sponsor: Gail Byrne, Chief Nursing Officer Author: Rosemary Chable, Head of Nursing for Education, Practice and Staffing Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information X Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future X X Executive Summary: a) The report details the methodology, findings, risk assessment and recommendations arising from the ward staffing review undertaken from July 2024 – October 2024. Recommendations in this report link to the statutory responsibilities arising from the National Quality Board (2016) expectations on ensuring safe, sustainable, and productive staffing, the NHS Improvement Developing Workforce Safeguards guidance (2018) and the Nursing Workforce Standards (RCN May 2021) assessed as part of CQC ‘safe’ and ‘well-led’ domain. The report outlines UHS progress in meeting the 38 recommendations included in the NICE guideline (2014) on safe staffing for in-patient wards and provides an update on the action – plan to achieve the recommendations in the national staffing levels guidance published by the National Quality Board in July 2016 (a key requirement of the NHSI ‘Developing workforce safeguards’ guidance (October 2018). b) To note findings of this annual ward establishment review and the Trust position in relation to adherence to the monitored metrics on nurse staffing levels, specifically: Overall, the staffing establishments remain appropriate and within recommended guidelines. There are some key exceptions where acuity and dependency levels and growing demand continue to outstrip the nursing ratios, coupled with the impact of ward reconfigurations – recommendations for uplifts in these areas will be put forward by the Divisions as part of the annual budget setting process.  UHS nursing establishments are set to achieve a range of 1:1 to 1:9 registered nurse to patient ratio in most areas during the day with the majority (43) set between 1:4 to 1:8. Differences relate to specialty and overall staffing model.  The majority of wards (32) are staffed at between 50:50 and 80:20 registered/unregistered ratio or above. Those wards with lower ratios (21 wards) are linked to the systematic and evaluated implementation of trained band 4 staff where appropriate and those with higher ratios (2) are both higher intensity care areas requiring a higher registered skill. 33 wards (down from 35 last year but remaining up significantly from 25 in 2019) are below the 60:40 ratio.  Planned total Care Hours Per Patient Day (CHPPD) range from 4.2 – 19.2 and average at 7.7  High levels of enhanced care demand, a reduced skill-mix and impact of financial controls have been highlighted as ongoing challenges for mitigation to ensure safe staffing. 1 The paper is presented for DISCUSSION. c) The report is presented in full to Trust Board as an expectation of the National Quality Board guidance on staffing which requires presentation and discussion at open board on all aspects of the staffing reviews. Contents: Paper; Appendix 1: National Quality Board (NQB Expectations for safe staffing Safe, Sustainable, and productive staffing; Appendix 2: NQB Safe Staffing Recommendations – UHS action plan; Appendix 3: NICE Guideline 1: Safe Staffing for nursing in adult inpatient wards in acute hospital - UHS action plan; Appendix 4: Ward by Ward staffing review metrics spreadsheet; Appendix 5: Specific Divisional issues emerging; Appendix 6: RCN Workforce Standards Risk(s): 1b – Due to the current challenges we fail to provide patients and families/carers with a highquality experience of care and positive patient outcomes. 3a – We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. Equality Impact Consideration: NO 2 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 2.0 2.1 2.1.1 2.1.2 Introduction or Background The purpose of this paper is to report on the outcomes of the review of ward staffing nursing establishments undertaken from July 2024 – October 2024. This 6-monthly review forms part of the Trust approach to the systematic review of staffing resources to ensure safe staffing levels effectively meet patient care needs. This paper focuses specifically on a review of nursing levels for in-patient ward areas. Areas such as maternity, critical care, theatres and the emergency department are reviewed separately. Divisional ‘light touch’ 6 monthly staffing reviews took place in March/April 2024 for all 4 clinical divisions and were reported to their relevant divisional boards and Nursing and Midwifery Staffing Review Group. Emergent themes have been incorporated into this review. The ward staffing review this year has taken place against the backdrop of financial recovery measures, some of which came into effect in Q4 of 2023/24 after the last annual staffing review with increasing measures being introduced in 2024/25. Discussions at the staffing review meetings focussed on any impact arising from the close monitoring and management of establishment levels and any mitigations/adjustments needed to continue to assure the delivery of safe care. It should also be noted that there were some key ward reconfigurations and refurbishments, some ward moves and a new ward opening since the last annual review and these areas have now been fully included in the annual cycle. The report also includes an update on the NICE clinical guideline 1 – Safe Staffing for nursing in adult inpatient wards in acute hospitals, issued in July 2014 and details progress with the action plan for adopting this guideline within UHS. This report fulfils expectation 1 and 2 of the National Quality Board requirements for Trusts in relation to safe nurse staffing and fulfils a number of the requirements outlined in the NHS Improvement ‘Developing Workforce Safeguards’ guidance (October 2018) which sets out to support providers to deliver high quality care through safe and effective staffing. This review also meets standards outlined in the RCN Nursing Workforce Standards (May 2021). Organisations are expected to be compliant with the recommendations in these reports and are subject to review on this as part of the CQC inspection programme under both the ‘safe’ and ‘well led’ domains. Analysis and Discussion Ward staffing review methodology In 2006 UHS established a systematic, evidence based and triangulated methodological approach to reviewing ward staffing levels on an annual basis linked to budget setting and to staffing requirements arising from any developments planned in-year. This was aimed to provide safe, competent and fit for purpose staffing to deliver efficient, effective and high-quality care and has resulted in consistent year-onyear review of the nursing workforce matched by increased investment where required. Following the National Quality Board expectations in 2014 and the refresh in 2016, a full review is now undertaken annually (with a light touch review at 6 months reporting to Divisional boards to ensure ongoing quality) with annual reporting to Trust Board in October/November. 3 2.1.3 The approach utilises the following methodologies:  Shelford Safer Nursing Care Tool Acuity/Dependency staffing multiplier (A nationally validated tool reviewed in 2013 - previously AUKUH acuity tool). Now incorporated into the Healthroster Safecare system  Care Hours Per Patient Day (CHPPD)  Professional Judgement  Peer group validation  Benchmarking and review of national guidance including Model Health System data  Review of eRostering data  Review of ward quality metrics 2.2 2.2.1 2.2.2 National guidance In 2013 as part of the national response to the Francis enquiry, the National Quality Board published a guide to nursing, midwifery and care staffing capacity and capability (2013) ‘How to ensure the right people, with the right skills, are in the right place at the right time.’ This guidance was refreshed, broadened to all staff, and reissued in July 2016 to include the need to focus on safe, sustainable and productive staffing. The NQB further reviewed this document and issued an updated recommendations brief in July 2017. The expectations outlined in this guide are presented in Appendix 1. These expectations are fulfilled in part by this review and the detailed action plan (Appendix 2) has been updated with progress towards achieving compliance with the 37 recommendations that make up the 3 over-arching expectations. The latest 4 monthly review of the action plan (November 2024) shows maintenance of compliance levels despite the ongoing activity and financial challenges. UHS remaining compliant with 35 of the 37 recommendations. The following 2 outstanding areas are progressing but require further action before being signed off: Allocated time for the supervision of students and learners: Staffing establishments take account of the need to allow clinical staff the time to undertake mandatory training and continuous professional development, meet revalidation requirements, and fulfil teaching, mentorship and supervision roles, including the support of preregistration and undergraduate students. Whilst there is some allowance within the 23% headroom, requirements for supervision are growing with revised initiatives around preceptorship, staff wellbeing and student supervision. Learner numbers (students, international and apprentices, preceptees) are increasing with limited additional supervisory support available. It is also important to note that the Ward Leader Supervisory allowance was put on hold in Q4 2023/24 and reinstated slowly from Q1 2024/25 as part of the trust recovery plan. This impacted short term on some of the supervision and support available to students and learners. Equality and diversity: The organisation has clear plans to promote equality and diversity and has leadership that closely resembles the communities it serves. The research outlined in the NHS provider roadmap42 demonstrates the scale and persistence of discrimination at a time when the evidence demonstrates the links between staff satisfaction and patient outcomes. Ongoing action through Equality & Diversity Group which is reported to Board separately. 4 2.2.3 2.2.4 2.2.5 2.2.6 2.2.7 2.3 2.3.1 In July 2014 NICE published Clinical Guideline 1: Safe Staffing for nursing in adult inpatient wards in acute hospitals. This guideline is made up of 38 recommendations. A detailed action plan was developed within UHS and is reviewed 4 monthly by the Nursing and Midwifery Staffing review group. The current assessment (November 2024) shows UHS has maintained compliance in 37 of the 38 recommendations. The 1 remaining recommendation is: Escalation actions taken to address deficits on one ward should not compromise another. Management of trustwide staffing deficits and thrice daily reviews of staffing via the staffing hub, as well as an improved recruitment situation, have minimised the risk of this. The close management and maintenance of minimal staffing levels, however, does not enable assurance that wards are not compromised by staff movements in extremis. The ongoing action plan is included at Appendix 3 detailing the recommendations and the UHS compliance position and actions in progress. In October 2018 NHS Improvement published ‘Developing Workforce Safeguards’ guidance which sets out to support providers to deliver high quality care through safe and effective staffing. It includes many of the actions identified in both the NICE guidance and the National Quality Board recommendations broadened to all staff groups. In May 2021 the Royal College of Nursing published their Nursing Workforce Standards (Appendix 6), developed as part of their safe staffing campaigns. The standards summarise the expectations in other national guidance and reiterates the importance of the Chief Nurse being responsible for setting nurse staffing levels based on service demand and user needs and the requirement to report directly to the Trustboard. Self-assessment undertaken by the Nursing and Midwifery Staffing Review Group (NMSRG) show UHS remains compliant with these standards. In October 2024 the RCN launched a review of these standards which are expected to be published at the end of the year. In light of this imminent review NMSRG have refreshed the self-assessment and confirmed that UHS remains compliant with the standards. In September 2022 a key research study was published (Zaranko B, Sanford NJ, Kelly E et al. BMJ Quality and Safety Epub) which highlights the link between higher registered nurse numbers and seniority and improved patient outcomes. Additionally in August 2024 an additional follow-up article (Griffiths, P; Saville C; Ball, J JAMA Network open) identified that substitution of registered gaps with temporary staff does not necessarily significantly lower the risks for patients. In late 2023 NIHR published an evidence based Professional Judgement Framework to support the application of professional judgement in nurse staffing reviews. Rosemary Chable and Natasha Watts from UHSFT were contributors to this guidance and are acknowledged in the authorship. This framework has been used as the basis for professional judgement throughout the staffing reviews. 6 monthly Ward Staffing review July 2024 – October 2024 – Outcomes The 6 monthly review was carried out from August 2024 – October 2024 with initial review meetings taking place with each Division (attended by DHN, Matrons, Ward Leaders, Finance representatives, workforce representatives and facilitated by the Head of Nursing for Education, Practice and Staffing). The same triangulated methodology was used as in previous reviews. An update on the latest guidance and reporting requirements in relation to staffing were also included in the divisional review meetings. 5 2.3.2 2.3.3 2.3.4 2.3.5 2.3.5.1 2.3.5.2 2.3.5.3 2.3.5.4 The detailed spreadsheet with ward-by-ward findings is included at Appendix 4. This provides information on the current establishment data broken down by shift and assessing against registered/unregistered ratios; CHPPD; nurse to patient ratios by registered and total nurse staffing and acuity information from Safecare where appropriate. It should be noted that a number of wards continue to be regularly reconfigured in response to the changing capacity and service situation, including new ward build and ward moves. A number of rostering template reviews were therefore instigated as a result of the review discussions so some figures may have changed for individual wards since the review. The staffing hub which was established in April 2020 to co-ordinate and oversee the real-time nurse staffing levels across the hospital in support of the clinical site function has continued to operate and adapt. It now maintains a stronger role in the daily deployment of staff and the ongoing management of bank/agency bookings and is having a measurable impact on the reduction in high-cost agency bookings. This is particularly evident in reviewing the deployment of bank and agency support for enhanced care. The hub activity is led by a daily designated staffing matron who takes responsibility for leading the continuous review and reassignment of the nurse staffing resource throughout the day. Nurse to patient ratios by registered and total nursing The ward establishments across UHS allow for registered nurse to patient ratios during the day to range from 1:1 (Piam Brown – Children) to 1:9 (Bassett, D6, D7 G6, G8, G9, E7 and E12) depending on specialty and overall staffing model. This is a further slight increase in the number of wards with lower RN: patient ratios (up from 4 wards to 8 wards with all areas in medicine) and this will require ongoing monitoring to ensure there is not further drift. The average level is set to achieve 1:4 to 1:8 registered nurse to patient ratio in most areas during the day (43 wards, previously 47) with 42 wards set between 1:4 to 1:7 (up from 38). Exceptions are where there has previously been a planned model of trained band 4 staff to mitigate recruitment challenges and is particularly evident in Medicine and Medicine for older people. The areas on or above 1:7 (22 wards) include the medicine wards, Medicine for Older People wards, some Trauma and Orthopaedic wards, including Brooke and the Acute Stroke Unit. These areas include a higher ratio of band 2 to 4 staff creating a total nurse to patient ratio of 1:3 – 1:4. It should be noted that the ratio of patients to registered nurse can regularly increase when wards are not fully established and these wards with lower RN to patient ratios are working on their minimum safe levels. Planned staffing ratios at night require constant oversight to ensure the model is sufficient to provide the required support for patients out of hours.  In areas that are working on lower staffing ratios, managing the workload at night has again emerged as an area that still requires action in a number of ward areas.  Wards are piloting different twilight shift patterns (within existing budget) to continue to support the demands at night.  Rising acuity of patients, more therapeutic activity taking place overnight and the impact of more geographically spread clinical areas has increased the pressure on the staffing resource at night. This also highlights the importance of supernumerary bleep-holders in supporting the ward areas 6 2.3.5.5 There are now 3 in-patient ward areas with ratios of 1:11 (RN to patient) at night (the same level as the previous year). These are E3(G), Acute Surgical Assessment and F7 this is offset by a total nurse to patient ratio of 1:5 and 1:6 with the utilisation of support staff. 2.3.6 2.3.6.1 2.3.6.2 2.3.6.3 2.3.6.4 2.3.6.5 2.3.6.6 2.3.6.7 Registered to unregistered ratios UHS ward areas were reviewed against the benchmark of 60:40 registered to unregistered ratios as the level to which ward establishments should ideally not fall below unless planned as the model of care. 15 wards are now rostered at between 60:40 and 70:30. This is an increase of 1 ward on last year when there had been a reduction of 5 wards. 32 wards (an improvement on the 35 in the previous year but still remaining up significantly from 25 in 2019) are below the 60:40 ratio. These wards are utilising band 4 staff as a key contribution to the model of care and are areas where there is a wider multidisciplinary team contributing to care (e.g., MOP, T & O, Medicine, Acute Stroke). It should be noted however that this reducing trend needs to be kept under close review against other metrics to ensure safe, quality care can be provided within the establishments. As highlighted previously, recent research highlights the impact on patient outcomes in areas with reduced registered nurse cover. 8 wards (1 more than 2023) are above the 70:30 ratio reflecting the increased specialism of our regional specialties where the intensity of the patient needs requires a higher ratio of registered staff (Child Health, CV&T, Neurosciences, and Cancer Care areas). The support of band 4 roles continues to be designed in as part of a model of care in a number of areas linked to the further development of apprenticeship opportunities. This has also provided a role in which to appoint the emerging cohorts of nursing associates who have qualified and registered with the NMC from January 2019 onwards. In many areas where the acuity and intensity of patients has increased, and treatment and medication regimes are complex, further reduction in the overall skill-mix of registered to unregistered staff is not appropriate to maintain safe staffing levels and ensure adequate supervision. Additionally, in some cases a band 4 model was used to mitigate ongoing gaps in registered roles – this was particularly notable in Medicine for Older People. As recruitment for registered nurses improves these areas will be reviewing the overall required skill mix model. Focus will continue on reviewing the overall registered to unregistered ratios to ensure reductions are linked to planned model of care changes and are accompanied by appropriate quality impact assessment and evaluation. The current review of band 2/3 banding linked to national job assimilation will not have an impact on the overall registered to unregistered ratios but will have a financial impact on the establishments where uplift results. It is important to note that this will need to be managed without reducing the overall availability of unregistered nursing hours in order to maintain staffing levels. 2.3.7 Assessment against the Safer Nursing Care Tool (acuity/dependency model)  The Safer Nursing Care Tool (acuity/dependency model) has been used to model required staffing based on the national recommended nurse to patient ratios for each category of patient in all the areas. This is integrated into the health roster system as part of the safe-care tool and provides information on acuity/dependency levels and corresponding staffing levels on a real-time basis converted into recommended care hours per patient day. Where the predicted levels differ from established numbers, professional judgement has been used to 7 assure that the levels set are appropriate for the speciality and number of beds. During the review period, a Trust-wide rollout of a new version of the software took place which has seen a total refresh of the use and application of the safer nursing care tool to ensure this is being used consistently across the organisation. There is also ongoing education and support work taking place to ensure all areas are using the tool in line with the recommendations to ensure consistency. 2.3.8 Care Hours Per Patient Day 2.3.8.1 Planned total Care Hours Per Patient Day (CHPPD) range from 4.2 (G5) rising to 19.2 (Piam Brown) and average at 7.7. The average is slightly lower than the previous year and there are a higher number of wards in the lower range. This will be linked to small bed increases in ward areas that have not been accompanied by staffing increases. 2.3.8.2 Planned Registered care hours per patient day range from 1.9 (G5) rising to 14.5 (Piam Brown) and average at 4.5. This average is slightly lower this year. 2.3.8.3 Planned Unregistered care hours per patient day range from 1.3 (C6 TYA) – 8.7 (G2 Neuro) and average at 3.2. This average is slightly lower than last year. 2.3.8.4 Actual CHPPD fluctuate significantly across the year and are strongly linked to patient numbers and changes in patient acuity. For example, increased staffing for patients who require enhanced care will increase the overall CHPPD numbers attributed to a ward. An aggregated Trust-wide average, whilst useful to review month by month and annually for a trend, are less meaningful than the granular review of each ward CHPPD. 2.3.9 Allowance for additional headroom requirements and supervisory ward leader model 2.3.9.1 All areas have 23% funding allocated to allow for additional headroom requirements arising from non-direct care time. It is recognised that in a number of areas this percentage is too low to cover all of the indirect requirements in an area, particularly related to speciality and supervisory and training needs. There remains significant pressure on maintaining staffing within the allowed headroom. This is due to high training levels (resulting from the more junior workforce) and maternity/paternity levels that consistently exceed the allowance. 2.3.9.2 New national initiatives and requirements of the NHS contract such as the implementation of Professional Nurse Advocacy for all staff and Preceptorship support for all new registrants has further increased the pressure on this set level of headroom. 2.3.9.3 A discussion around management of headroom was included in each of the ward staffing reviews which took place with clear actions for the ward leaders to implement. 2.3.9.4 UHS has an established Ward Leader Supervisory model which means the Ward Leader is not included in the established numbers required to deliver safe care per shift. This enables them to focus more time on supervising and leading the ward team whilst supporting clinical care. This proved particularly important during recent years with developing the junior workforce. 2.3.9.5 In Q4 2023/24 and Q1 24/25 this model was paused as part of the financial recovery plan and Ward Leaders were rostered directly to support shifts. This impacted a range of indicators including appraisal completion, sickness reviews, roster management and learner development. In Q2 this was reinstated as part of the workforce plan for nursing and key metrics have again improved. The model is used flexibly whilst the priority is always to ensure safe staffing levels on the wards. Ward 8 Leaders clearly articulated the personal and professional impact of this pause during the discussions at the review meetings. 2.3.10 Specific Divisional issues emerging Specific Divisional issues highlighted in the review are contained in Appendix 5. 2.4 Trust wide risks and issues considered in the review 2.4.1 Establishment monitoring and controls in line with financial recovery The staffing reviews took place against the backdrop of ongoing financial recovery. During the review period inpatient areas have been working to 97% of establishments (with identified exceptions) as a control measure and this is being monitored weekly to ensure any impact on quality indicators and staff wellbeing are flagged and responded to in a timely way to ensure safe staffing in line with NQB standards. Issues arising from these measures were openly discussed at the staffing reviews. 2.4.2 Increasing patient acuity/dependency The ongoing development of our defining services continues to result in an evidenced increase in the complexity, acuity and dependency of the patients cared for in our general ward beds, also linked to reducing length of stay. COVID-19 has had a significant impact as our patients are definitely presenting with a higher level of both acuity and dependency. Information on the acuity and dependency of our patients is available via the ‘Safe Care’ functionality in health roster and is used in real time as part of our daily staffing meetings. The information is also used at the 6 monthly reviews as part of the professional judgment assessment. 2.4.3 Increasing enhanced care needs Trust wide we have continued to see an increase in the complexity of patients particularly in relation to mental health needs including dementia and patients remaining in the acute settings for prolonged lengths of time whilst awaiting appropriate placements. We have also seen a significant rise in the episodes of violence and aggression experienced in our clinical areas which creates additional needs for staffing support. This continues to have an impact on the ability to support the additional enhanced care needs that arise for these groups of patients particularly across key specialties (MOP, Medicine, Child Health, Neurosciences, T & O and latterly Surgery). Division B retain the Trustwide overview for enhanced care, specifically mental health support, and provide an advice service, supporting clinical areas in their decision making around the need for additional support. Divisions have then developed enhanced care bays on wards and/or a local pool of staff to deploy to support enhanced care needs. Ward leaders report that this has made a major difference to the management of patients with these enhanced needs and has reduced the reliance on last minute agency to support. The numbers however remain unpredictable and are therefore managed in real-time as part of overall considerations around safe staffing. The management of additional enhanced care needs extends beyond the definition of patients requiring formal mental health support. Increased numbers of patients with 9 challenging behaviour or needing 1:1 presence brings additional pressures to ward establishments but are necessary to keep the environment safe for all patients. Through the work completed in agreeing and setting an affordable workforce level for 24/25 there was recognition and agreement to fund enhanced care based on 2023/24 M10 position, as an addition to establishments. This has had a positive impact and has resulted in a reduction in usage due to the controls in place and leadership/oversight from the matrons. During 24/25 the staffing hub has been co-ordinating the requests for additional staff with additional mental health needs specifically linked to the mental health support team. This has shown key reductions in the use of registered mental health staff and tangible financial savings but despite these efforts, demand has continued to outstrip supply. 2.4.3 Supervising and supporting the junior workforce The professional judgement discussions with all the Ward Leaders again highlighted the additional challenges posed to the staffing models of appropriately supervising and supporting the increasing range of learners having placements on the ward areas. This includes the ability to meet the supervisory standards with an increasingly junior workforce. New national guidance was issued in October 2022 and implemented within UHS during 2023 with additional requirements in relation to the provision of preceptorship for all staff new to registration. Protected time for both preceptors and preceptees is now an expectation for organisations. The robust retention and recruitment strategies across the Trust and the strong vision to ‘grow our own’ nurses for the future means that wards continue to support a range of learners including undergraduate students, trainee nursing associates, nurse degree apprentices, Return to Practice students, newly registered staff undergoing preceptorship and internationally educated nurses awaiting registration. Education teams across the trust have proved key to supporting the development and learning into the wards and particularly in continuing to train and support learners to full registration and into preceptorship. The capacity and capability within the education and support teams needs to be further reviewed for 25/26 and beyond to ensure they can continue to support the further increase in numbers which will be required for UHS to meet the challenging workforce targets set in the national plan - with nursing student placements alone set to increase by up to 230% in the southeast over the coming years. 2.4.4 Benchmarking using the Model Health System UHSFT provides data monthly to the national Model Hospital System (MHS) detailing the actual CHPPD provided (based on patient numbers) for all clinical areas including critical care. During 2024 the uploads to this system from UHS have been resubmitted following some data anomalies over the summer. It is unclear whether all of the corresponding graphs and information have been amended following this change. Direct comparison of ward areas or specialty is no longer available via the benchmarking system however an overall average of total CHPPD is available to review via peer group and this is used as part of the staffing review. Hospitals with a high volume of critical care beds (providing 1:1 care) will have a 10 higher CHPPD. Table 1 Organisation/Group Total CHPPD Registered CHPPD Unregistered CHPPD UHS excl. Critical Care 8.7 4.8 3.9 UHS with Critical Care 10.5 6.7 3.8 Shelford Group 9.8 6.7 3.2 MHS Peer Group 9.56 5.7 3.4 Region 8.9 5.6 3.3 National 8.7 5.1 3.5 All data submissions (registered and unregistered) are averaged so will not necessarily equal the total CHPPD) Data is from the MHS August 2024 (latest figure) and includes nursing and midwifery and ward AHP staffing. and the UHS excluding critical care is UHS reporting Sept 2024 figure from People Report just for nursing. 2.4.5 Review of quality metrics and staffing incidents The NICE guidance outlines some key quality metrics that should be considered as part of the staffing reviews. The safety metrics defined are patient falls, pressure ulcers and medicine administration errors. These metrics, along with a range of other UHS defined quality indicators are already monitored through our internal clinical quality dashboard and are discussed ward by ward as part of the professional judgement methodology in the reviews. In addition, there is ongoing review of red flags raised as part of the adverse event reporting system and on ‘safecare’. 3.0 Conclusion 3.1 A robust ward staffing establishment review was undertaken using a mixed methodology of approaches and in line with recommendations from the National Quality Board, NICE guidance, and the RCN Nursing Workforce Standards 3.2 Overall the staffing establishments remain appropriate and within recommended guidelines. There are some key exceptions where acuity and dependency levels and growing demand continue to outstrip the nursing ratios, coupled with the impact of ward reconfigurations – recommendations for uplifts in these areas will be put forward by the Divisions as part of the annual budget setting process. 4.0 Recommendations 4.1 To discuss the report at Trust Executive Committee and Trust Board as an ongoing requirement of the National Quality Board and developing workforce safeguards guidance around safe staffing assurance. 4.2 To note findings of this annual ward establishment review and the Trust position in relation to adherence to the monitored metrics on nurse staffing levels. 4.3 To note the ongoing progress in UHS compliance with the guidance from the National Quality Board on safe, sustainable, and productive staffing. 4.4 To note the ongoing progress in UHS compliance with the NICE guideline on safe staffing for nursing in adult inpatient wards. 4.5 To note and acknowledge the ongoing risks and challenges of matching actual staffing to established staffing levels and to agree the continuous monitoring of this with the introduction of any additional financial recovery measures. 11 4.6 To support the continued Trust wide commitment and momentum on actions to fill clinical nursing vacancies and further reduce the reliance on high-cost agency against the backdrop of rising acuity and emergency and elective recovery. 4.7 Systematic ward staffing reviews to be reported to board annually, with 6 monthly light touch reviews reported through Divisional Boards. Next full staffing review to be presented to Trust Board in November 2025. 5.0 Appendices Appendix 1: National Quality Board (NQB Expectations for safe staffing Safe, Sustainable, and productive staffing Appendix 2: NQB Safe Staffing Recommendations – UHS action plan Appendix 3: NICE Guideline 1: Safe Staffing for nursing in adult inpatient wards in acute hospital - UHS action plan Appendix 4: Ward by Ward staffing review metrics spreadsheet Appendix 5: Specific Divisional issues emerging Appendix 6: RCN Workforce Standards 12 Appendix 1 National Quality Board Expectations for safe staffing - Safe, Sustainable, and productive staffing (July 2016) Expectation 1: Right staff  Boards should ensure there is sufficient and sustainable staffing capacity and capability to provide safe and effective care to patients at all times, across all care settings in NHS provider organisations.  Boards should ensure there is an annual strategic staffing review, with evidence that this is developed using a triangulated approach (i.e., the use of evidence-based tools, professional judgement, and comparison with peers), which takes account of all healthcare professional groups and is in line with financial plans.  This should be followed with a comprehensive staffing report to the board after six months to ensure workforce plans are still appropriate.  There should also be a review following any service change or where quality or workforce concerns are identified.  Safe staffing is a fundamental part of good quality care, and CQC will therefore always include a focus on staffing in the inspection frameworks for NHS provider organisations.  Commissioners should actively seek to assure themselves that providers have sufficient care staffing capacity and capability, and to monitor outcomes and quality standards, using information that providers supply under the NHS Standard Contract. Expectation 2: Right skills  Boards should ensure clinical leaders and managers are appropriately developed and supported to deliver high quality, efficient services, and there is a staffing resource that reflects a multi professional team approach.  Decisions about staffing should be based on delivering safe, sustainable, and productive services.  Clinical leaders should use the competencies of the existing workforce to the full, further developing and introducing new roles as appropriate to their skills and expertise, where there is an identified need or skills gap. Expectation 3: Right place and time  Boards should ensure staff are deployed in ways that ensure patients receive the right care, first time, in the right setting. This will include effective management and rostering of staff with clear escalation policies, from local service delivery to reporting at board, if concerns arise.  Directors of nursing, medical directors, directors of finance and directors of workforce should take a collective leadership role in ensuring clinical workforce planning forecasts reflect the organisation’s service vision and plan, while supporting the development of a flexible workforce able to respond effectively to future patient care needs and expectations. 13 Appendix 2 Expectation 1: Right staff NATIONAL QUALITY BOARD - JULY 2016 Supporting NHS Providers to deliver the right staff with the right skills, in the right place at the right time - safe sustainable and productive staffing - NURSING & MIDWIFERY Assessed UHS rating Descriptor No. Recommendation Current measures in place (November 2024) C = compliant Boards should ensure there is sufficient A = Actions required and sustainable staffing capacity and 1.1 Evidence-based workforce planning capability to provide safe and effective Triangulated approach to care to patients at all times, across all care settings in NHS provider organisations. Boards should ensure there is an annual 1.1.1 strategic staffing review, with evidence that this is developed using a triangulated approach (i.e. the use of evidence-based The organisation uses evidence-based guidance such as that produced by NICE, Royal Colleges and other national bodies to inform workforce planning, within the wider triangulated approach in this NQB resource (see Appendix 4 for list of evidence-based guidance for nursing and midwifery care staffing). staffing establishments well embedded. Shelford SNCT used and embedded in 'safecare' as part of eRostering. NICE guidance systematically reviewed 3 x per year. C tools, professional judgement and comparison with peers), which takes The organisation uses workforce tools in accordance with their account of all healthcare professional groups and is in line with financial plans. 1.1.2 guidance and does not permit local modifications, to maintain the All tools used as reliability and validity of the tool and allow benchmarking with recommended. C This should be followed with a peers. comprehensive staffing report to the board after six months to ensure Workforce plans contain sufficient provision for planned and 23% included in all direct care in-patient areas. workforce plans are still appropriate. 1.1.3 unplanned leave, e.g. sickness, parental leave, annual leave, Compliance monitored as C There should also be a review following training and supervision requirements. part of healthroster reporting any service change or where quality or suite workforce concerns are identified. Safe staffing is a fundamental part of 1.2 Professional judgement good quality care, and CQC will therefore always include a focus on staffing in the inspection frameworks for NHS provider organisations. Commissioners should actively seek to assure themselves that providers have sufficient care staffing capacity and 1.2.1 Clinical and managerial professional judgement and scrutiny are a crucial element of workforce planning and are used to interpret the results from evidence-based tools, taking account of the local context and patient needs. This element of a triangulated approach is key to bringing together the outcomes from evidencebased tools alongside comparisons with peers in a meaningful way. 6 monthly staffing reviews include face to face meetings with Corporate Nursing Team/DHN/Matron/ward leaders as well as workforce systems and finance. Professional judgement key part of the reviews. C capability, and to monitor outcomes and quality standards, using information that providers supply under the NHS Standard Contract. 1.2.2 Professional judgement and knowledge are used to inform the skill mix of staff. They are also used at all levels to inform real-time decisions about staffing taken to reflect changes in case mix, acuity/dependency and activity. As above. Professional judgement also used as part of the daily staffing review meetings through site control. C Identified actions required and notes on compliance Timescale Continue with current approach and strengthen with the use of CHPPD and safecare complete Need to ensure there is corporate rigour on adapting SNCT while rolling out 'safecare'. Monitor the impact on the inclusion of 'enhanced care' scoring. Participate in the national NIHR research Ongoing compliance monitored as part of healthroster reporting suite. Increased headroom requirement due to COVID-19 complete complete Continue with current approach and strengthen with the use of CHPPD and safecare complete Continue with current approach. Professional judgement remains the ultimate measure of safe staffing. Key part of the staffing hub set-up during COVID-19 complete 1.3 Compare staffing with peers Lead Head of Nursing staffing/DMT Head of Nursing staffing/DMT DoF/Chief Nurse Head of Nursing staffing/DMT Head of Nursing staffing/DMT/site team 1.3.1 Previous ad hoc The organisation compares local staffing with staffing provided by peers, where appropriate peer groups exist, taking account of any underlying differences. benchmarking included through AUKUH network and targeted at specific services under development. Need to strengthen and formalise C Build on the current benchmarking capabilities included in the Model Hospital and N&M Dashboard. Continue to utlise the 'civil eyes' data for child health. Work with eRoster provider to introduce reporting that includes benchmarking data complete Head of Nursing staffing/workforce systems team 1.3.2 1.3.3 The organisation reviews comparative data on actual staffing alongside data that provides context for differences in staffing requirements, such as case mix (e.g. length of stay, occupancy rates, caseload), patient movement (admissions, discharges and transfers), ward design, and patient acuity and dependency. The organisation has an agreed local quality dashboard that triangulates comparative data on staffing and skill mix with other efficiency and quality metrics: e.g. for acute inpatients, the model hospital dashboard will include CHPPD. All considered as part of the systematic staffing reviews Clinical Quality Dashboard (CQD) includes all staffing and quality metrics. Used as part of the systematic clinical accreditation scheme reviews Model hospital benchmarking now C being used routinely. All services benchmark with other areas where complete Head of Nursing staffing/DMT appropriate C Build the model hospital work into the CQD complete Head of Quality and Clinical Assurance Appendix 2 Boards should ensure clinical leaders and managers are appropriately developed 2.1 Mandatory training, development and education and supported to deliver high quality, efficient services, and there is a staffing resource that reflects a multiprofessional 2.1.1 Frontline clinical leaders and managers are empowered and have the necessary skills to make judgements about staffing and assess their impact, using the triangulated approach outlined in team approach. Decisions about staffing this document. should be based on delivering safe, sustainable and productive services. Clinical leaders should use the competencies of the existing workforce to the full, further developing and introducing new roles as appropriate to their skills and expertise, where there is an identified need or skills gap. All frontline leaders skilled to manage staffing agenda. Included in competencies for ward leaders 2.1.2 Staffing establishments take account of the need to allow clinical staff the time to undertake mandatory training and continuous professional development, meet revalidation requirements, and fulfil teaching, mentorship and supervision roles, including the support of preregistration and undergraduate students. 23% headroom allowance and provision of supervisory ward leader role covers most aspects of time identified but not fully assured around adequate time for supervision of all learners. Backfill provided for some roles in development degree apprenticeships but does not cover release for all staff C Continue to maintain competence, skills and knowledge through master classes and staffing review meetings complete Head of Nursing staffing/DMT 23% headroom is included in all nursing establishments as well as an allowance in all areas for the Ward Leader to be supervisory. A number of additional requirements e.g. increased student numbers and supervision, increased numbers of junior staff needing more supernumerary training time and A professional nurse advocacy have led Unable to to the 23% allocation falling short of identify an the needs in a number of areas. expected date This is particarly notable in critical for compliance. care and ED where the training needs Mitigations in outstrip the provision in the 23% place Head of Nursing staffing/DHN's/Divisional Education Leads/Education Quality Lead headroom. Important to note that the Ward Leader Supervisory allowance was put on hold in Q4 2023/24 and reinstated slowly from Q1 2024/25 as part of the trust recovery plan. This impacted short term on some of the non-direct activities and KPI's eg appraisal rates/progression/HR actions 2.1.3 Those with line management responsibilities ensure that staff are All expectations clearly managed effectively, with clear objectives, constructive appraisals, included in JD and annual and support to revalidate and maintain professional registration. objectives for line managers C Monitored as part of ongoing HR key performance metrics complete Associate Director of People/DMT 2.1.4 The organisation analyses training needs and uses this analysis to Annual training needs help identify, build and maximise the skills of staff. This forms part analysis process well of the organisation’s training and development strategy, which embedded within the annual also aligns with Health Education England’s quality framework. cycle for the trust C Continue with current approach with review in 2020 to further streamline priorities to staffing needs and match to changed CPD arrangements . complete Divisional Education Leads/Education Quality Lead/DMT 2.1.5 The organisation develops its staff’s skills, underpinned by Comprehensive training knowledge and understanding of public health and prevention, and programmes in place to supports behavioural change work with patients, including self- equip staff with required care, wellbeing and an ethos of patients as partners in their care. skills C Monitored through ongoing evaluation complete Director of TD&W/Divisional Education Leads//DMT 2.1.6 2.1.7 The workforce has the right competencies to support new models of care. Staff receive appropriate education and training to enable them to work more effectively in different care settings and in different ways. The organisation makes realistic assessments of the time commitment required to undertake the necessary education and training to support changes in models of care. Comprehensive training programmes in place to equip staff with required skills The organisation recognises that delivery of high quality care depends upon strong and clear clinical leadership and well-led and motivated staff. The organisation allocates significant time for team leaders, professional leads and lead sisters/charge nurses/ward managers to discharge their supervisory responsibilities and have sufficient time to coordinate activity in the care environment, manage and support staff, and ensure 100% Supervisory ward leader time provided in all inpatient direct care areas. Clinical leaders programme in place standards are maintained. C Monitored through ongoing evaluation complete Director of TD&W/Divisional Education Leads//DMT Continue to review % of time Head of Nursing - C achieved as supervisory linked to complete staffing/DMT/workforce ongoing vacancy position systems 2.2 Working as a multiprofessional team 2.2.1 The organisation demonstrates a commitment to investing in new roles and skill mix that will enable nursing and midwifery staff to spend more time using their specialist training to focus on clinical duties and decisions about patient care. The organisation recognises the unique contribution of nurses, Range of new roles developed and evaluated within the organisation. Extended scope policies in place to support. Further strengthen the trustwide Director of C approach to service by service complete TD&W/Divisional workforce development Education Leads//DMT midwives and all care professionals in the wider workforce. Multiprofessional approach to 2.2.2 Professio
Url: /Media/UHS-website-2019/Docs/About-the-Trust/performance/TB-6-monthly-staffing-review-report.pdf

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

Description: Date Time Location Chair Agenda - Trust Board Meeting 29/09/2020 9:00 - 16:00 Microsoft Teams Peter Hollins 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 To note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. Minutes of Previous Closed Meeting held on 27 August 2020 (Not for publication) Matters Arising and Summary of Agreed Actions (Not for publication) OPEN ITEMS (For publication) 2 QUALITY, PERFORMANCE and FINANCE 2.1 Patient Story To receive feedback from patients, carers, or other stakeholders about their experience of the Trust's services. 2.2 Briefing from Chair of Charitable Funds Committee for review (Oral) 9:15 Dave Bennett, Chair 2.3 Briefing from Chair of Finance & Investment Committee for review (Oral) 9:20 Jane Bailey, Chair 2.4 Briefing from Chair of People & OD Committee for review (Oral) 9:25 Jenni Douglas-Todd, Chair 2.5 Integrated Performance Report for Month 5 for assurance 9:30 To review the Trust's performance as reported in the Integrated Performance Report Sponsor: Paula Head, Chief Executive 2.5.1 10:15 Access Targets: Cancer Trajectory Update for review Sponsor: Joe Teape, Chief Operating Officer 2.5.2 10:25 ED Performance & Recovery Plan Update for review Sponsor: Joe Teape, Chief Operating Officer 2.6 Violence and Aggression Progression Report for review 10:40 Sponsor: Joe Teape, Chief Operating Officer Attendee: Sandra Hodgkyns, Head of Security/Emergency Planning (LSMS) 2.7 Workforce Race Equality Standard (WRES) and Workforce Disability 10:50 Equality Standard (WDES) Annual Reports 2019/20 for review and Action Plans 2020/21 for review Sponsor: Steve Harris, Chief People Officer Attendee: Gemma Genco, Head of Equality, Diversity and Inclusivity 2.8 Black, Asian and Minority Ethnic (BAME) Experience Improvement Plan 11:05 for approval Sponsor: Steve Harris, Chief People Officer Attendees: Gemma Genco, Head of Equality, Diversity and Inclusivity/ John Norton, Chair, BAME One Voice Network 2.9 Finance Report for Month 5 for review 11:20 Sponsor: David French, Chief Financial Officer 3 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 3.1 Feedback from Council of Governors' meeting 1 September 2020 (Oral) 11:35 Sponsor: Peter Hollins, Trust Chair 3.2 Register of Seals, and Chair's Actions for ratification 11:45 In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Peter Hollins, Trust Chair 4 Follow-up Discussion with Governors 11:50 5 To note the date of the next meeting: 29 October 2020 in the Conference Room, Heartbeat/Microsoft Teams (Closed meeting only) 6 Items Circulated to the Board for reading 6.1 CRN: Wessex 2020/21 Quarter 1 Performance Report Sponsor: Derek Sandeman, Chief Medical Officer Page 2 2.5 Integrated Performance Report for Month 5 for assurance 1 Integrated Performance Report 2020-21 Month 5 Report to the Trust Board of Directors dated Tuesday 29 September 2020 Title: Agenda item: Sponsor: Date: Purpose Issue to be addressed: Integrated Performance Report 2020/21 Month 5 2.5 Chief Executive 22 September 2020 Assurance Approval or reassurance Y Ratification Information This report is intended to support the Trust Board in assuring that: • the care we provide is safe, caring, effective, responsive and well led in the context of the Covid 19 pandemic • at the same time we continue our journey toward our vision of World Class Care for Everyone. Response to the issue: For the year 2020/21 the Integrated Performance Report has adapted to reflect the current operating environment. In particular we have aligned it with the Care Quality Commission Key Lines of Enquiry and then cut it again to reflect delivery of our Strategic Goals and annual corporate objectives. Implications: This report covers a broad range of trust services and activities. It is (Clinical, Organisational, intended to assist the Board in assuring that the Trust meets regulatory Governance, Legal?) requirements and corporate objectives. Risks: (Top 3) of carrying This report is provided for the purpose of assurance. out the change / or not: Summary: Conclusion This report is provided for the purpose of assurance. and/or recommendation Page 1 of 24 Integrated KPI Board Report covering up to Aug 2020 Sponsor - Andrew Asquith, Director of Financial and Productivity Improvement, andrew.asquith@uhs.nhs.uk Page 2 of 24 Chart Type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line Percentiles Control Chart Variance from Target Report Guide Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). A line percentiles chart is used to represent the distribution of a variable. The 50th percentile shows the median value, we also show the 5th, 25th (lower quartile), 75th (upper quartile) and 95th centiles. A control chart shows movement of a variable in relation to it's control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts are used to show how far away a variable is from it's target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving it's target. 2 Page 3 of 24 Report to Trust Board in September 2020 Introduction The Trust Integrated Performance Report is presented to the Trust Board each month. For the year 2020/21 the Integrated Performance Report has adapted to reflect the current operating environment. In particular we have aligned it with the Care Quality Commission Key Lines of Enquiry and then cut it again to reflect delivery of our Strategic Goals and annual corporate objectives in order to: • Demonstrate that we can assure ourselves that the care we provide is safe, caring, effective, responsive and well led in the context of the Covid 19 pandemic • Ensure that at the same time we continue our journey toward our vision of World Class Care for Everyone. We might adjust/ or add to these indicators – informing the Board and keeping a comparative narrative – if the situation changes as we work through these unusual circumstances. An example of this might be measuring vulnerable groups as the evidence around COVID emerges. The monthly Trust Integrated Performance Report is currently complemented by a ‘Covid-19 Balanced Scorecard’ which is considered by the UHS Integrated Assurance Group, and also available to Board Members, on alternate weeks. August 2020 Summary During August the direct impact of Covid 19 infections upon the Trust continued to reduce. The number of beds occupied by patients with Covid 19 remained in low single figures and at times there were 0 Covid 19 inpatients. Over a 2 week period we tested 0 positive staff or patients. Covid 19 in the local community also remained low, with infection rates estimated at 4-7 per 100,000. Non-elective admission volumes in total remained at approximately 90% of their normal levels. Elective spells increased to approximately 72% of their normal levels. Elective activity continued to be adversely affected by the need to socially distance, particularly in outpatients, infection control guidance (which was relaxed for some cases in the middle of August) and the inability to fill theatre lists when patients cancelled at the last minute because of the need to isolate for 14 days. The trust has sought to prioritise the reduced elective capacity available towards those patients requiring assessment or treatment more urgently, and to provide assessments by telephone or video whenever appropriate. The trust started to develop detailed speciality specific recovery plans in August, in line with the Wave 3 letter, as well as each service 3 Page 4 of 24 Report to Trust Board in September 2020 RESPONSIVE • Emergency Department timeliness deteriorated in August, reaching 85.9% across the month (RE 10). Other Trusts have also seen similar deterioration, though UHS had the fourth best performance out of 8 ‘peer’ Major Trauma Centres (RE9). Attendance numbers increased to approximately 85% of the normal level (RE 8), whilst enhanced infection control precautions remained in place. • The percentage of patients waiting up to 18 weeks from referral to treatment improved marginally to 55% (RE 14). The total number of patients waiting is now above pre-Covid levels, at 34,900 patients (RE 15), and is expected to increase further, due to the recovery in the number of referrals being made to hospital (RE 12). The percentage of patients waiting more than 6 weeks for a diagnostic test (RE 20) improved from 35% to 40%, though the total number of patients waiting continued to increase and is now above pre-Covid levels (RE 19). The average waiting time for new outpatient appointments further reduced in August and is now at 8.8 weeks (RE 18). • Cancer performance measures for July indicate that UHS 62 day performance (RE 21) improved and is now the best amongst our 10 ‘peer’ teaching hospitals, and that 31 day performance (RE 22) further improved to 98.2% and achieved the national standard. The number of patients still waiting with pathways greater than 104 days (RE 23) reduced from 36 to 17. There remain challenges particularly in the head and neck tumour site. 4 Page 5 of 24 Report to Trust Board in September 2020 RESPONSIVE Jun Jul Aug Sep Oct Nov Dec Jan 6,800 6,533 RE1 Non-elective Spells (including CDU) Feb Mar Apr May Jun Jul Aug Monthly Target 6,058 - 4,000 7.5 RE2-L Non Elective LOS Rolling 12 months 6.42 6.0 250 RE3 Number of patients medically optimised for discharge Longer LOS Census average RE4-N (Patients with LOS > =21days) 0 211 227.34 180.19 133.04 - 6.10 123 - 137 - RE5-l Adult midday bed occupancy 95.2% 72.4% 90-95% RE6 Last minute cancelled operations not readmitted within 28 days 3 150 78 RE7 Hospital initiated cancelled ops 91% 80.3% 81% 85.04% 90.7% 71% 766545365325334 Patients spending less than 4hrs in ED RE10-N UHS Total (includes SGH all types and lymington until Jul 19) 91.51% 83.3% 75.05% 82.2% 85.9% 91.27% Q Target - 95% 95% RE11-N Total time spent in ED Total Percentiles UHS Mean, 3:16 50th, 3:06 90th, 4:07 Mean, 2:50 - - 50th, 2:47 RE12 Accepted Referrals 25000 22249 14883 - - RE13 Elective spells 0 2,000 0 1,453 1,191 - - 6 Page 7 of 24 Report to Trust Board in September 2020 RESPONSIVE RE14-N % Patients on an open 18 week pathway (within 18 weeks ) Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 83% 84.0% 78% 72% 54.75% Target > =92% 35000 Total number of patients on a waiting RE15-N list (18 week referral to treatment pathway) RE16 Face to face outpatient attendances 28000 50,000 52,480 33746 34903 24,043 - RE17 Non-face to face outpatient attendances 0 50,000 7,948 0 RE17 - Latest month is awaiting approx ~3k outpatient attendances to be reported 12,900 - RE18 Average weeks waited for first outpatient appointment 9,000 RE19 Patients waiting for diagnostics 4,000 RE20-N % of Patients waiting over 6 weeks for diagnostics 19% 121%% 7.5 7004 2.8% 8.8 - 8794 - 39.61% RE22-N 31 day cancer wait performance (latest data held by UHS) no.patients Target to recover QTD Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul /July 1 94.5% 78.4% N=> N = 12 90% L=> L= 17 of 84% 76.5% 72.6% 95% 111.5 36578645655121 0.5 96.2% 92.4% 88.5% 98.22% N=> 96% N=0 of 805 0.9665821 RE23 Snapshot of waits > 104 days (from referral on a 62 day pathway) 33 38 41 55 52 41 29 35 27 29 11 25 36 17 - - 100% RE24-N 28 Day Faster Diagnosis 70% 10,000 RE25 My Medical Record - UHS patient logins 5,000 0 2500 RE26 Number of Estates Help desk requests and percentage completed on time 900 100% 85% 75% 4,634 1620 81.0% 85% => 75 % - 7,132 - 1516 - 89.6% > 85% 50% 79.80% 89.0% 8 Page 9 of 24 Report to Trust Board in September 2020 RESPONSIVE 50% Monthly Target Target QTD /July - Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Elective inpatient activity - % of same time last year 60.00% 50.19% RE27 UHS Corporate peer average ------------------------------Rank--> 48.32% 000000000047330 0.00% Non-elective inpatient activity - % of same time last year RE28 UHS 110.00% 108.41% 100.61% Corporate peer average ------------------------------Rank--> 000000000046650 0.00% 1st outpatient attendances - % of same time last year 100.00% 96.80% RE29 UHS Corporate peer average ------------------------------Rank--> 70.70% 000000000065570 0.00% 9 Page 10 of 24 Report to Trust Board in September 2020 SAFE • The majority of measures indicate that safety has been maintained during August. • New Covid-19 diagnoses amongst hospital inpatients (SA5, SA6) have reduced significantly, and there were no cases of ‘probable’ transmission or ‘healthcare-acquired’ Covid-19 in UHS inpatient services in August. The Covid 0 campaign continued to be rolled out, focusing on the absolute importance of stopping nosocomial COVID infection. The campaign encourages all people to follow government guidance when walking apart, wear a mask where you can’t, and continue to wash your hands as often as possible. • Statutory and mandatory training compliance further reduced in August. • Both clinical and Serco cleaning scores showed an improvement in August; with both meeting 100. • As expected CHPPD for all areas this month is still elevated at 11.0 (RN 6.7, HCA 4.3) with ward only areas also elevated at 9.4 (RN 5.0, HCA 4.4). This is reflective of new ward configurations, roster changes, additional staff deployments and reduced patient numbers in some areas. • In UHS ward-based areas, the data shows that total nursing staff vacancies have increased to 9.63%. Registered nurse vacancies in ward-based areas have decreased this month to 15.52%. This position is being continuously validated as data, sourced from rosters, has been affected by the significant ward changes in size and specialty focus that have occurred as a result of the COVID-19 restart plan. Annual ward staffing reviews are currently taking place to confirm required levels against the changed configurations. Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target YTD YTD Target SA1-N Cumulative Clostridium difficile 2 SA2 MRSA bacterium 0 100 SA3 Clinical cleaning scores for very high risk areas 99 95 SA4 Serco cleaning scores for very high risk areas 100 99 95 27 5 32 32 0 0 100 98 - 14days after admission 00 0 0 0 0 0 0 0 0 20 30 14 1 0 0 Probable hospital-associated 50 SA6 COVID infection: COVID-positive sample taken > 7 days and 95% - 96.3% YTD Target - - > 95% 12 Page 13 of 24 Report to Trust Board in September 2020 CARING • The majority of measures indicate that UHS has continued to provide caring services during August. • Friends and family negative scores remained below target, at 3.7% (CA1), although maternity saw an increase for the second month, rising to 8.3% (CA2). • Complaints per 1,000 units remained significantly below the target, at 0.27 (CA4). The number of complaints closed on time continues to make a slow recovery following the pausing of complaints investigation at the height of Covid 19. In August the Trust achieved 46%, compared to 41% in July (CA5) • The percentage of women receiving ‘Continuity of Care’ within the Maternity service remained static at 11% and remains well below the target of 35%. A plan has been developed to drive improvements in this aspect of care. • The number of non-clinically justified overnight ward moves rose slightly in August, to 68 (CA9). An action plan is being developed to reduce these. Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target 0.6% CA1-N FFT Negative Score - Inpatients 5% =35% 1.30 CA4-L Complaints per 1000 units 0.00 CA5-L % Complaints closed within 35 days 80% 0% 0.38 81% Page 14 of 24 =70% 13 Report to Trust Board in September 2020 0% Jun Jul Aug Sep 100% % Patients reporting being CA6 involved in decisions about care and treatment 50% 100% % Patients reporting finding CA7 somebody to talk to about worries and fears 50% 100% % Patients with a CA8 disability/additional needs reporting those needs/adjustments were met 50% CA9 Overnight ward moves with a reason marked as non-clinical Jun Jul Aug Sep 135.76 99 76.96 18.16 18.0 Total nursing staff all inpatient CA10 areas - Care hours per patient day13.0 (CHPPD) 8.0 40.0 Same Sex Accommodation CA11 (Non Clinically Justified Breaches) 20.0 2 0.0 9.0 11 4 4 CARING Oct Nov Dec Jan Feb Mar Apr May Jun Oct Nov Dec Jan Feb Mar Apr May Jun 32 12 1 1 0 15 0 0 0 Monthly Target Jul Aug 84% > =90% 91% > =90% 94% > =90% Monthly Jul Aug Target 68 - 11.0 - - 0 0 14 Page 15 of 24 Report to Trust Board in September 2020 EFFECTIVE • The number of patients screened for alcohol and smoking continued to significantly exceed the 80% target, at 97% (EF5) • The number of patients found to have either a moderate or high dependence on alcohol (EF6), or to smoke (EF7) who were given advice or an onward referral continued to exceed the targets, at 80% and 94% respectively. EF1-L Cumulative Specialities with Outcome Measures Developed Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 47 52 52 53 54 223 234 250 255 260 Monthly Target +1 100% EF2 Developed Outcomes RAG ratings 75% 78% 77% 79% 80% 81% 50% 100 EF3-N HSMR - UHS HSMR - SGH 81 75 4.5% EF4 HSMR - Crude Mortality Rate 2.9% 80% 15 Page 16 of 24 Report to Trust Board in September 2020 EFFECTIVE 80% Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug % patients screened & found to EF6-N have either moderate or high alcohol dependence given advice 90% 87% 80% or referral 70% % patients screened & found to 100% 83% 94% EF7-N smoke given brief advice or a medication offer 60% Monthly Target > 90% > 90% 16 Page 17 of 24 Report to Trust Board in September 2020 WELL LED • Turnover this month has increased due to the student nurses who joined the trust to support for covid have started to return to their University courses and this has strongly affected the turnover % this month, and is likely to continue next month as these students are leaving UHS. • In clinical ward areas there are 163 registered nurses and 153 healthcare assistants in the covid ‘at risk’ categories who are unable to be deployed to some patient-facing activities. The majority of these staff have now been deployed to low risk areas, as risk levels are continuously reviewed. All nursing staff have been flexibly deployed to manage this deployment safely. A review is ongoing with covid assessments to move our system to be covid age instead of risk level 1 – 3. • This month staffing remains amber overall because some key targets have been missed for staff turnover, sickness and appraisals. The in-month sickness absence rate has seen a decrease and is below its normal position, but the 12 month figure is elevated due to the spoke during the pandemic. • Statutory and mandatory training compliance has seen some slippage (with 6 of 12 measures meeting target) due to COVID-19 and the reductions in training release during that time. • Recognising the pause in appraisals during COVID efforts are now being focused on improving quantity undertaken whilst retaining the important focus on quality of discussion as reflected in our staff survey. • UHS has seen an increase in rates of employment for BAME Band 7+ to 9.37%, but is still on an upwards trend. UHS is now monitoring BAME individual occupying 35 key medical leadership positions. This will be reported on a quarterly basis. WL1-L Substantive Staff - Turnover Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target 13.90% 13.18% 12.46% 12.8% 13.3% 92% 77.24% 17 Page 18 of 24 Report to Trust Board in September 2020 WELL LED Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target WL3-L 100.00% Staff - Medical appraisals completed - Rolling 12-months 50.00% 0.00% 60.00% WL4-L Staff vacancies 10.00% 5.00% 0.00% 4.09% WL5-L Staff - Sickness absence 4.43% 3.7% 2.99% 3.31% 2.91% =76% 30% 20% WL9-L Black & Minority Ethnic Band 7+ Percentage 9% 8.8% 9.4% 15% by 2023 7% WL10 Cumulative Number of staff trained in QI 1001 1064 1171 WL10 - QI training programme, and reporting, is currently temporarily suspended as team members support urgent change programmes as part of our Covid 19 response and recovery WL11 Statutory & Mandatory Training Achieving Target 8 8 8 8 7 7 7 7 7 7 7 6 6 6 6 4 4 4 4 5 5 5 5 5 5 5 6 6 6 6 - 100 WL12 Number of Apprenticeship Starts 53 - 50 29 28 23 0 19 Page 20 of 24 Report to Trust Board in September 2020 WELL LED 0 Monthly Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Target WL13-L Comparative CRN Recruitment Performance by clinical specialty 44% 44% 52% 56% 52% > =50% 2 WL14-L Comparative CRN Recruitment Performance - weighted 4 5 5 6 Top 5 WL15-L Comparative CRN Recruitment - contract commercial 15 15 13 13 13 Proportion of studies closing in FY on 88% WL16-L time and to recruitment target - 59% 65% 65% 50% non-commercial 452 WL17 NIHR CRF & BRC publications Year on year growth 329 246 137 Top 10 > =80% 20 Page 21 of 24 Report to Trust Board in September 20C20hanges and Corrections Section Responsive Responsive Responsive KPI KPI Name Type Elective inpatient activity - % RE26 of same time last year Addition Non-elective inpatient RE27 activity - % of same time last Addition year 1st outpatient attendances - RE28 % of same time last year Addition Detail Addition of benchmark position - % activity compared to same time last year, with rank and average of corporate peer group CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST OXFORD UNIVERSITY HOSPITALS NHS FOUNDATION TRUST SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST UNIVERSITY HOSPITALS BRISTOL AND WESTON NHS FOUNDATION TRUST UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST 21 Page 22 of 24 Nursing and midwifery staffing hours - Aug 2020 Report notes Our staffing levels are monitored daily and we will risk assess and fill any gaps to ensure that safe staffing levels are always maintained The total hours planned is our planned staffing levels to deliver care across all of our areas but does not represent a baseline safe staffing level. We plan for an average of one registered nurse to every five or seven patients in most of our areas but this can change as we regularly review the care requirements of our patients and adjust our staffing accordingly. Staffing on intensive care and high dependency units is always adjusted depending on the number of patients being cared for and the level of support they require. Therefore the numbers will fluctuate considerably across the month when compared against our planned numbers. Enhanced Care (also known as Specialling) Occurs when patients in an area require more focused care than we would normally expect. In these cases extra, unplanned staff are assigned to support a ward. If enhanced care is required the ward may show as being over filled. If a ward has an unplanned increase or decrease in bed availability the ward may show as being under or over filled, even though it remains safely and appropriately staffed. CHPPD (Care Hours Per Patient Day) This is a measure which shows on average how many hours of care time each patient receives on a ward /department during a 24 hour period from registered nurses and support staff - this will vary across wards and departments based on the specialty, interventions, acuity and dependency levels of the patients being cared for. The maternity workforce consists of teams of midwives who work both within the hospital and in the community offering an integrated service and are able to respond to women wherever they choose to give birth. This means that our ward staffing and hospital birth environments have a core group of staff but the numbers of actual midwives caring for women increases responsively during a 24 hour period depending on the number of women requiring care. During the last 2 weeks in March and beyond a number of our clinical areas started to change specialty and size to respond to the COVID-19 situation (e.g G5-G9, Critical Care and RHDU). Repurposing of wards to respond to the COVID-19 social distancing recommendations and to enable the separation and restart of services continues with changes sometimes being swift in nature. The data may in some cases not be fully reflective of these changes. WARD C4 (Solent ward) C4 (Solent ward) C6 C6 C6 (Teenage Cancer Trust unit) C6 (Teenage Cancer Trust unit) D2 D2 D3 D3 Critical Care Critical Care E5A E5A E5B E5B F10 E F10 E F11 F11 ASU ASU F6 F6 F5 F5 Acute medical unit Acute medical unit D5 D5 D6 D6 D8 D8 D9 D9 E7 E7 Respiratory high dependency unit Respiratory high dependency unit C5 C5 D10 D10 f7 f7 G5 G5 G6 G6 G7 G7 G8 G8 G9 G9 Registered nurses Total hours planned Registered nurses Total hours worked Unregistered staff Total hours planned Unregistered staff Total hours worked Registered nurses % Filled Day 1383.7 1370.1 1048.9 1253.3 99.0% Night 1069.3 1011.8 713.0 1176.8 94.6% Day 2791.3 2783.6 183.5 414.7 99.7% Night 2049.3 2097.4 102.4% 0.0 320.0 Day 727.5 564.5 331.9 334.8 77.6% Night 674.0 597.0 88.6% 0.0 96.7 Day 1303.0 1671.0 1108.0 909.8 128.2% Night 1057.5 1058.3 713.0 759.0 100.1% Day 1685.5 1641.7 689.2 1157.0 97.4% Night 1046.3 1083.5 686.3 812.5 103.6% Day 21459.4 18076.5 4440.8 2978.6 84.2% Night 20549.2 17565.5 2736.5 2251.8 85.5% Day 1339.7 1171.4 723.4 1019.4 87.4% Night 714.0 679.5 356.5 701.5 95.2% Day 1413.6 1190.3 811.5 1112.0 84.2% Night 713.0 713.0 356.5 597.8 100.0% Day 2313.5 1483.1 623.0 1277.7 64.1% Night 1069.5 1001.5 713.0 793.5 93.6% Day 1953.9 1405.9 774.8 1011.3 72.0% Night 713.0 713.8 713.0 885.5 100.1% Day 1480.3 1056.8 417.5 589.0 71.4% Night 695.0 718.0 356.5 327.5 103.3% Day 2306.0 1384.7 576.8 1345.9 60.0% Night 1069.5 1030.8 701.5 850.0 96.4% Day 1969.1 1534.2 1322.9 1268.3 77.9% Night 1069.5 991.5 712.5 873.5 92.7% Day 3572.8 4020.6 3294.5 3737.1 112.5% Night 3548.8 4008.4 2495.5 3893.3 113.0% Day 1255.0 1313.0 1668.0 1572.3 104.6% Night 1046.5 993.0 934.5 858.0 94.9% Day 1120.5 1061.3 1522.0 1441.5 94.7% Night 713.0 750.5 945.5 820.5 105.3% Day 1134.0 1009.5 1467.5 1700.0 89.0% Night 713.0 794.5 945.5 954.0 111.4% Day 1247.0 1350.7 1711.0 1590.8 108.3% Night 1069.5 978.0 945.5 980.5 91.4% Day 1080.5 1102.5 1232.0 1466.2 102.0% Night 713.0 681.5 713.0 702.5 95.6% Day 1256.3 992.0 521.0 346.5 79.0% Night 1143.0 1037.3 356.5 164.5 90.7% Day 860.0 1037.7 1285.0 602.0 120.7% Night 701.5 678.5 437.0 352.0 96.7% Day 1122.5 995.2 1301.0 1377.0 88.7% Night 702.0 656.5 713.0 552.0 93.5% Day 1083.7 980.4 1749.5 1649.0 90.5% Night 977.5 805.5 713.0 724.5 82.4% Day 1021.0 1277.2 1799.3 1700.8 125.1% Night 1058.8 932.3 701.5 839.5 88.1% Day 1061.9 1049.9 1782.5 1866.0 98.9% Night 1046.5 943.0 713.0 782.0 90.1% Day 742.5 742.5 1354.5 1679.5 100.0% Night 701.5 708.5 1069.5 1092.5 101.0% Day 1079.7 1041.6 1841.2 1829.0 96.5% Night 1069.5 874.0 713.0 805.0 81.7% Day 1080.8 1063.0 1768.8 1910.3 98.4% Night 1070.5 932.5 713.0 736.0 87.1% Unregistered staff % Filled 119.5% 165.0% 226.0% Shift N/A 100.9% Shift N/A 82.1% 106.5% 167.9% 118.4% 67.1% 82.3% 140.9% 196.8% 137.0% 167.7% 205.1% 111.3% 130.5% 124.2% 141.1% 91.9% 233.4% 121.2% 95.9% 122.6% 113.4% 156.0% 94.3% 91.8% 94.7% 86.8% 115.8% 100.9% 93.0% 103.7% 119.0% 98.5% 66.5% 46.1% 46.8% 80.5% 105.8% 77.4% 94.3% 101.6% 94.5% 119.7% 104.7% 109.7% 124.0% 102.2% 99.3% 112.9% 108.0% 103.2% CHPPD Registered midwives/ nurses CHPPD Care Staff 5.0 5.1 8.0 1.2 10.4 3.9 6.2 3.8 5.0 3.6 26.3 3.9 3.7 3.5 3.8 3.4 4.8 4.0 4.1 3.6 8.1 4.2 3.5 3.2 4.1 3.4 7.9 7.5 3.2 3.4 3.4 4.3 2.7 3.9 2.8 3.1 3.1 3.8 16.6 4.2 9.8 5.4 3.3 3.9 3.5 4.6 2.9 3.3 2.9 3.9 3.5 6.6 2.6 3.5 2.9 3.8 CHPPD Overall 10.0 9.2 14.2 10.0 8.6 30.1 7.2 7.2 8.8 7.7 12.3 6.6 7.5 15.5 6.6 7.7 6.6 5.9 7.0 20.8 15.2 7.2 8.1 6.2 6.9 10.1 6.1 6.7 Comments Safe staffing levels maintained. Safe staffing levels maintained. Safe staffing levels maintained; additional staff used for enhanced care - Support workers. Safe staffing levels maintained. Staff moved to support other wards; Staffing appropriate for number of patients. Staff moved to support other wards; Staffing appropriate for number of patients. Safe staffing levels maintained. Safe staffing levels maintained. Safe staffing levels maintained; additional staff used for enhanced care - Support workers. Safe staffing levels maintained. Beds flexed to match staffing. Beds flexed to match staffing. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers; Additional staff working in this area due to covid restrictions. Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers. Safe staffing levels maintained; Additional staff used for enhanced care - Support workers. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care Support workers. Safe staffing levels maintained. Safe staffing levels maintained by sharing staff resource; Staffing appropriate for number of patients. Safe staffing levels maintained by sharing staff resource; Staffing appropriate for number of patients. Band 4 staff working to support registered nurse numbers; Beds flexed to match staffing; Safe staffing levels maintained; Covid testing zone requiring additional staffing. Band 4 staff working to support registered nurse numbers; Beds flexed to match staffing; Safe staffing levels maintained; Covid testing zone requiring additional staffing. Safe staffing levels maintained. Safe staffing levels maintained. Safe staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained; Additional staff used for enhanced care Support workers. Additional staff used for enhanced care - RNs; Safe staffing levels maintained. Additional staff used for enhanced care - RNs; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Safe staffing levels maintained. Beds flexed to match staffing; Staff moved to support other wards; Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Beds flexed to match staffing; Staff moved to support other wards; Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained; Beds flexed to match staffing. Staff moved to support other wards; Safe staffing levels maintained; Beds flexed to match staffing. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care - Support workers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Additional staff used for enhanced care - Support workers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. Page 23 of 24 Nursing and midwifery staffing hours - Aug 2020 Report notes Our staffing levels are monitored daily and we will risk assess and fill any gaps to ensure that safe staffing levels are always maintained The total hours planned is our planned staffing levels to deliver care across all of our areas but does not represent a baseline safe staffing level. We plan for an average of one registered nurse to every five or seven patients in most of our areas but this can change as we regularly review the care requirements of our patients and adjust our staffing accordingly. Staffing on intensive care and high dependency units is always adjusted depending on the number of patients being cared for and the level of support they require. Therefore the numbers will fluctuate considerably across the month when compared against our planned numbers. Enhanced Care (also known as Specialling) Occurs when patients in an area require more focused care than we would normally expect. In these cases extra, unplanned staff are assigned to support a ward. If enhanced care is required the ward may show as being over filled. If a ward has an unplanned increase or decrease in bed availability the ward may show as being under or over filled, even though it remains safely and appropriately staffed. CHPPD (Care Hours Per Patient Day) This is a measure which shows on average how many hours of care time each patient receives on a ward /department during a 24 hour period from registered nurses and support staff - this will vary across wards and departments based on the specialty, interventions, acuity and dependency levels of the patients being cared for. The maternity workforce consists of teams of midwives who work both within the hospital and in the community offering an integrated service and are able to respond to women wherever they choose to give birth. This means that our ward staffing and hospital birth environments have a core group of staff but the numbers of actual midwives caring for women increases responsively during a 24 hour period depending on the number of women requiring care. During the last 2 weeks in March and beyond a number of our clinical areas started to change specialty and size to respond to the COVID-19 situation (e.g G5-G9, Critical Care and RHDU). Repurposing of wards to respond to the COVID-19 social distancing recommendations and to enable the separation and restart of services continues with changes sometimes being swift in nature. The data may in some cases not be fully reflective of these changes. Paediatric high dependency unit Paediatric high dependency unit Paediatric medical unit Paediatric medical unit Paediatric intensive care unit Paediatric intensive care unit Piam Brown ward Piam Brown ward E1 E1 G2 G2 G3 G3 G4 G4 Bramshaw women's unit Bramshaw women's unit Neonatal unit Neonatal unit Maternity service Maternity service Cardiac high dependency unit Cardiac high dependency unit Coronary care unit Coronary care unit D4 D4 E2 E2 E3 Green E3 Green E3 Blue E3 Blue E4 E4 Acute stroke unit Acute stroke unit Regional transfer unit Regional transfer unit E Neuro E Neuro Hyper acute stroke unit Hyper acute stroke unit D neuro D neuro SPI F4 Neuro SPI F4 Neuro Brooke ward Brooke ward Trauma Assessment Unit Trauma Assessment Unit F1 F1 F2 F2 F3 F3 F4 F4 Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night 1627.5 1069.5 1835.4 1707.5 6762.1 5697.8 3695.9 1415.1 2068.0 1380.0 759.3 744.0 2410.6 1705.0 2429.0 1705.0 1120.0 713.0 6894.9 5439.5 8456.9 5383.8 4548.2 3653.1 1412.2 1331.8 1756.2 820.0 1721.2 704.0 1574.8 704.0 1181.7 665.0 1652.1 1100.5 1518.5 1023.0 773.0 682.0 1975.5 1364.0 1564.0 1358.0 1941.0 1364.5 1817.4 1089.0 1171.2 1069.5 535.5 341.0 2428.4 1781.8 1655.7 1023.0 1606.3 1023.3 1470.0 1023.0 1320.0 1162.5 2753.9 2438.4 4695.4 4443.2 2723.0 1178.6 1523.8 1193.8 780.1 793.0 1683.9 1350.8 1994.5 1324.5 1047.3 712.5 4472.4 3814.3 7597.2 4577.8 3991.0 3358.8 1864.8 1613.0 1425.2 780.3 1057.2 706.0 1394.2 682.0 975.7 621.0 1320.7 1069.0 1520.0 880.0 729.5 506.0 1719.0 1265.0 1181.5 924.0 1831.8 1310.0 1254.7 924.0 917.5 736.0 648.7 617.3 1980.8 1736.9 1455.8 803.0 1320.0 869.3 1364.2 860.3 0.0 0.0 352.2 680.5 726.2 587.8 93.0 0.0 620.0 371.3 0.0 0.0 1691.0 1023.0 1188.0 682.0 656.5 345.0 1551.0 1353.0 3137.4 2046.0 2233.7 1366.0 1089.0 968.0 1057.5 1012.0 866.4 341.0 1398.5 788.3 1150.5 682.0 1285.9 396.0 2674.5 1705.0 387.5 330.0 1031.0 1021.5 397.5 319.0 2033.5 1715.0 1143.0 1043.0 600.3 356.5 313.6 341.0 1936.3 1755.3 2000.5 1375.3 1791.2 1364.3 1217.2 693.8 81.1% Shift N/A 92.0 15.6 0.6 Non-ward based staff supporting areas; Safe staffing levels maintained. 16.2 108.7% 0.0 Shift N/A Safe staffing levels maintained. 150.0% 182.0% Additional beds open in the month; Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained. 640.9 21.0 5.5 26.5 713.5 142.8% 104.8% Additional beds open in the month; Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained. 269.0 472.8 69.4% 78.0% 37.0% 80.4% Beds flexed to match staffing. 39.1 3.2 42.2 Beds flexed to match staffing. 158.5 73.7% 170.4% 12.4 0.5 Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. 12.9 83.3% 0.0 Shift N/A Beds flexed to match staffing; Safe staffing levels maintained. 641.0 73.7% 103.4% 7.8 Band 4 staff working to support registered nurse numbers; Non-ward based staff supporting areas; Safe staffing levels maintained. 3.6 11.4 614.8 86.5% 165.6% Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. 102.7% Shift N/A 0.0 12.0 0.0 Safe staffing levels maintained. 12.0 106.6% 0.0 Shift N/A Safe staffing levels maintained. 791.0 69.9% 46.8% 8.4 Non-ward based staff supporting areas; Safe staffing levels maintained; Beds flexed to match staffing. 3.6 12.0 532.5 79.2% 52.1% Beds flexed to match staffing; Safe staffing levels maintained. 885.5 82.1% 74.5% 8.4 Non-ward based staff supporting areas; Safe staffing levels maintained; Beds flexed to match staffing. 3.7 12.1 583.0 77.7% 85.5% Beds flexed to match staffing; Safe staffing levels maintained. 609.0 93.5% 92.8% Safe staffing levels maintained. 8.1 4.4 12.6 345.0 99.9% 100.0% Safe staffing levels maintained. 1605.5 64.9% 103.5% 10.7 3.3 Staffing flexed to match bed numbers. 14.0 946.0 70.1% 69.9% Staffing flexed to match bed numbers. 2498.7 89.8% 79.6% Safe staffing levels maintained. 5.3 1.9 7.2 1770.8 85.0% 86.5% Safe staffing levels maintained. 1394.4 803.0 87.7% 91.9% 62.4% 58.8% Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the Unit; Band 4 staff working to support 19.0 5.7 24.7 registered nurse numbers. Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the Unit; Band 4 staff working to support registered nurse numbers. 132.0% 81.1% Additional beds open in the month; Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the 883.5 9.5 4.6 14.1 Unit. 814.0 121.1% 84.1% Additional beds open in the month; Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the Unit. 81.2% 139.7% Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained; Support workers used to maintain staffing 1477.8 4.4 4.9 9.3 numbers. 95.2% 92.9% Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained; Support workers used to maintain staffing 940.0 numbers. 61.4% 163.7% Staffing appropriate for number of patients; Staff moved to support other wards; Band 4 staff working to support registered nurse 1418.5 3.9 4.7 8.6 numbers. 687.4 100.3% 201.6% Staffing appropriate for number of patients; Staff moved to support other wards; Increased night staffing to support raised acuity. 1381.3 88.5% 98.8% 3.8 Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. 4.0 7.8 801.3 96.9% 101.6% Band 4 staff working to support registered nurse numbers; Safe staffing levels maintained. 1119.0 781.0 1192.9 748.0 2645.5 1815.0 234.5 396.0 1594.5 1439.5 495.0 427.8 1668.0 1550.5 1435.5 1197.0 585.8 563.5 827.6 660.0 2307.9 1852.0 2242.3 1572.3 2170.0 1486.0 1033.7 915.5 82.6% 93.4% 79.9% 97.1% 100.1% 86.0% 94.4% 74.2% 87.0% 92.7% 75.5% 68.0% 94.4% 96.0% 69.0% 84.8% 78.3% 68.8% 121.1% 181.0% 81.6% 97.5% 87.9% 78.5% 82.2% 84.9% 92.8% 84.1% 97.3% 114.5% 92.8% 188.9% 98.9% 106.5% 60.5% 120.0% 154.7% 140.9% 124.5% 134.1% 82.0% 90.4% 125.6% 114.8% 97.6% 158.1% 263.9% 193.5% 119.2% 105.5% 112.1% 114.3% 121.1% 108.9% 84.9% 132.0% Band 4 staff working to support registered nurse numbers; Patient requiring 24 hour 1:1 nursing in the month. 4.1 4.8 8.9 Band 4 staff working to support registered nurse numbers; Patient requiring 24 hour 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Staffing appropriate for number of patients; Support workers used to maintain 5.8 4.7 10.6 staffing numbers. Additional staff used for enhanced care - Support workers; Skill mix swaps undertaken to support safe staffing across the Unit; Support workers used to maintain staffing numbers. Patient requiring 24 hour 1:1 nursing in the month; Band 4 staff working to support registered nurse numbers; Support workers used to 3.1 5.7 8.7 maintain staffing numbers. Patient requiring 24 hour 1:1 nursing in the month; Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month; Low bed numbers but staff on roster being used in neuro swabbing hub making it look like working on ward in 18.2 9.3 27.4 report. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 5.9 6.0 11.8 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 14.0 6.2 20.2 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month. Patient requiring 24 hour 1:1 nursing in the month; Band 4 staff working to support registered nurse numbers; Support workers used to 5.8 5.9 11.8 maintain staffing numbers. Patient requiring 24 hour 1:1 nursing in the month; Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 5.3 6.4 11.6 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Patient requiring 24 hour 1:1 nursing in the month. Safe staffing levels maintained by sharing staff resource; Staff moved to support other wards; Skill mix swaps undertaken to support safe 5.2 3.6 8.8 staffing across the Unit. Safe staffing levels maintained by sharing staff resource; Staff moved to support other wards; Skill mix swaps undertaken to support safe staffing across the Unit. Safe staffing levels maintained by sharing staff resource; This ward has a high number of admissions and acuity/dependency of patients 8.7 10.3 19.0 which means more Registered nurse and support workers are required. Safe staffing levels maintained by sharing staff resource; This ward has a high number of admissions and acuity/dependency of patients which means more Registered nurse and support workers are required. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to 4.5 5.1 9.6 support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to 3.2 5.3 8.5 support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to 3.9 6.5 10.3 support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to 4.5 3.9 8.4 support safe staffing across the Unit; Staff moved to support other wards. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels maintained by sharing staff resource; Skill mix swaps undertaken to support safe staffing across the Unit; Staff moved to support other wards. Page 24 of 24 2.5.1 Access Targets: Cancer Trajectory Update for review 1 Access Targets: Cancer Trajectory Update Report to the Trust Board of Directors dated 29 September 2020 Title: Agenda item: Sponsor: Date: Purpose Issue to be addressed: Response to the issue: Access Targets: Cancer Trajectory Update 2.5.1 Joe Teape, Chief Operating Officer 16 September 2020 Assurance Approval or reassurance Ratification Information Yes To provide an update to Trust Board on cancer performance following the last report that went to Trust Board in March 2020 and the impact of Covid19 on performance. The report provides an update on UHS cancer performance and covers the following; • Current performance against the key cancer metrics • Challenges faced during Covid-19 and impact on demand • Changes made in managing patients on a cancer pathway Implications: (Clinical, Organisational, Governance, Legal?) Clinical Organisational Governance and risk Risks: (Top 3) of carrying out the change / or not: The top 3 risks are: • Inability to meet required cancer standard targets • Inability to manage cancer patients during a Covid-19 pandemic • Risk of increase in cancer referrals of patients whose cancer may have spread so that the cancer will be harder to treat or no longer be curative Summary: Conclusion and/or recommendation The Trust Board is asked to consider the recent cancer performance and note the impact of COVID 19 has had on activity/demand and performance. The Board is asked to note whilst we have seen improvements in performance since April 2020 there remain significant risks to achievement and further work is being undertaken to develop mitigations & assess the impact of improving referral times from other organizations which impact on UHS. Page 1 of 7 1. Introduction/Background In March 2020 Trust Board was provided with an update on cancer performance and plans on acti
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Papers Trust Board - 13 January 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 13/01/2026 9:00 - 13:00 Conference Room, Heartbeat Education
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Papers Trust Board - 7 January 2025

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

Papers Trust Board - 29 November 2022

Description: Date Time Location Chair Agenda Trust Board – Open Session 29/11/2022 9:00 - 13:20 Conference Room, Heartbeat/Microsoft Teams
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2022-Trust-documents/Papers-Trust-Board-29-November-2022.pdf

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