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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
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2026-Trust-documents/Papers-Trust-Board-13-January-2026.pdf

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
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Papers-Trust-Board-7-January-2025.pdf

A guide to your child's CADD pump - patient information

Description: This factsheet explains what a computerised ambulatory delivery device (CADD) pump is, how it works and how to use it safely at home.
Url: /Media/UHS-website-2019/Patientinformation/Childhealth/A-guide-to-your-childs-CADD-pump-3793-PIL.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

Recipe book - For toddlers who need to make the most of every mouthful

Description: RECIPE BOOK For toddlers who need to get the most out of every mouthful Contents 04 Acknowledgements & introduction 06 Questions, tips & answers 12 Table 01: Foods which can be used for extra calories and protein 13 Table 02: Examples of exercise and the benefits 14 Food & feeding advice for young children (table) 16 Simple week meal planner 18 Shopping list 20 Recipes: Contents 22 Recipes: Breakfasts � Marvelous nut dust � Granola � Breakfast porridge � Prunes, dates & ground almonds � Peaches, sultanas & ground almonds � Mango & almond butter � Raspberry, banana & almonds 28 Recipes: Power energy balls � Date & apricot power balls 29 Recipes: Warming soups � Dino soup � Super hero orange soup 31 Recipes: Bento boxes � Fusilli, ham, peas & cheese � Ham & cheese pitta & fresh fruit � Ham & cheese sandwich, broccoli, cucumber, orange & nutty chocolate balls � Falafel & hummus pitta, red pepper, cucumber, figs, strawberries � Cream cheese & smoked salmon wheels, avocado & melon � Pitta strips, avocado, hummus, chickpeas, orange peppers � satsumas � Tuna, lettuce, mayo, peas, cucumber, & pepper � Boiled eggs, brown pitta pockets, avocado, watermelon, melon & raspberries � Avocado & raspberries snack fest � Peanut butter, salad & berries � Chicken & BBQ sauce, corn on the cob, cucumber, clementine, & whole wheat wrap � Chicken & cous cous rainbow salad 43 Recipes: Snack boxes 44 Recipes: Meals for sharing � family favourites � Fish fingers & sweet potato chips � Pasta bolognaise � Lasagne � Mild chicken curry � Chicken bunny � Pesto � Salmon, pasta & peas 57 Recipes: Sweet things � Chocolate & almond cup cakes � Apricot, almond & chocolate cereal bars � Nutty flapjacks � Fruit pots � Chocolate peanut butter smoothie � Raspberry & almond smoothie 66 A last note... enjoy... 02 Acknowledgements This book has been written by Dr Luise Marino (RD, PhD) Clinical Academic Paediatric Dietitian at Southampton Children's Hospital. This book is part of independent research arising from (Dr Luise Marino, Health Education England/NIHR Clinical Lectureship (ICA-CL-2016-02-001)) supported by the National Institute for Health Research. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research, Health Education England or the Department of Health. In writing this book we have received the generous help and feedback from the following people: � Parents of children who need to make the most of every mouthful � thank you for your time and feedback, without which this book would not be possible � Paediatric Dietitians � Catherine Kidd, Natalie Davies � for your expertise and invaluable comments � Dr Rosan Meyer � for sharing your immense knowledge and skills � Paediatric Speech and Language Therapist � Julia Robinson � for your guidance and practical instruction � Specialist Paediatric Cardiac Liaison Nurses � Gill Harte, Colette Cochran, Cate Anson, Hannah Carver � for your unfailing support, feedback and advice � Dr Tara Bharucha, Consultant Paediatric Cardiologist � for supporting this initiative � Members of the British Dietetic Association Paediatric Cardiology Interest group for their generous help and feedback; in particular Neam Al Mossawi (HCA Healthcare), David Hopkins (Yeovile Hospital) � Dominic and Helen Hoile (info@Shootingpeas.com) � for their generosity opening up their studio and giving of their time to take the photographs. � Heather Pierpoint (headfudgedesign.co.uk) � Graphic designer, for bringing the publication to life � Southampton Children's Hospital Charity and the publishers � Michelle Wheeler, Judith Stephens, Amy McBrayne, Alanna Lee for making it all possible � Nutricia Medical � for supporting the project with an educational grant Dedication For all the families and their children who we are privileged to meet � your stories and journeys inspire us to do better. RECIPE BOOK For young children who need to get the most out of every mouthful Who is this book intended for? This book is intended for children between 1 and 5 years of age. Some children need a little bit longer with puree or fork mashed food so don't worry if your child is not quite at the age stages in this book. Some children are born with medical conditions which means they need to get the most out of everything they eat and drink. For some, whose medical issues may not be such a problem as they were when they were babies, they may now develop feeding difficulties, causing parents just as much concern. This recipe book is part of a series, published by Southampton Hospital Charity, to provide practical advice on how children can get the most of every mouthful. The advice within this booklet may not be suitable for those with delayed oral motor skills, inherited metabolic disorders, kidney problems or food allergies and should not replace individualised medical or nutritional advice. If you are unsure as to whether the advice in this book is suitable for your child, please check with their health care team first. The information in this book was correct, at the time of publishing, and undergoes periodic reviews to ensure up-to-date evidence is used. You should seek advice from your local health care professional if your child is not gaining weight well or is having feeding difficulties. Dr Luise Marino (RD, PhD) Clinical Academic Paediatric Dietitian HEE/NIHR ICA Clinical Lectureship thank you Ask for help If your child is showing signs of feeding difficulties (sensory or oro-motor disorders) which can include coughing, gagging or vomiting at the sight or smell of food or drink, food refusal, eating less than 10 different types of food in a week or you are in any way worried about how your child eats, then ask your child's team to refer you to Dietitian and Speech & Language Therapist for extra support. How will this book help me and my child? The aim of this book is to try and provide some useful tips and advice as well as some finger licking food to tempt your little one with. This book will help give you ideas about: � � � � � � How much to expect your child to eat How often should you expect your child to eat What textures can you expect your child to eat How to create a positive mealtime experience How to cope with stressful mealtimes How to cope with fussy eating 05 Questions, tips & answers... How much should I expect my child to eat? The amount of food young children eat varies from one meal to the next � this is normal. There are lots of resources available providing portion size ranges � with some examples below: � British Nutrition Foundation: https://www.nutrition.org.uk/ attachments/article/734/BNF%20 Toddler%20Eatwell%20Leaflet_OL.pdf � Infant and Toddler Forum https://www.infantandtoddlerforum. org/portion-sizes-table-2015 How often should I offer my child food? Try to have: � Regular mealtimes � aiming for breakfast, lunch and supper � Have at least a 3 hour break between each main meal � this will give them enough time to get hungry, but not too hungry � Try not to offer too many snacks between meals as they may then not be able to eat as much at a main meal � If your child is too tired they may find it difficult to eat, so sometimes lunch may be better after a nap � Offer water to drink at mealtimes � It is alright for your child still to prefer puree food � but continue to try to introduce lumpier and soft finger foods too � This will let children practice their chewing skills try to slowly increase the amount of texture in the meal e.g. 5p � 10p amount of a coarser texture until you have moved onto chunkier and lumpier food � Always give some finger food and a spoon at each mealtime so new skills can be practiced � bite and dissolve foods are good as are other finger foods (see the table at the end of this section for more tips) � Remember all of the senses are involved in eating and drinking; touch, sounds, sight and smells; - We eat food with our eyes, so it is important to make food look good - Touching food is as important as eating, so let your little one get messy - Smells of delicious food can encourage children to eat � Try not to compare how much your little one eats with siblings or other children of the same age � Try not to comment on how much or how well your little one is eating, some children get put off eating by all of the attention and focus on them � Don't follow your child around with a spoon begging them to eat; meals happen as a picnic or at a table not walking around � Encourage your little one to feed themselves; sometimes children like the attention of being fed, but it is good to encourage their feeding skills by letting them do it themselves � Children of all ages like food in boxes � Bento boxes, sandwich boxes or little bags or boxes of food appeal to their growing sense of independence � Food that little fingers can easily pick up is good as they can be more independent � don't worry if they play with it and get messy as this is all part of their learning experience � Eat with them � have a meal or snack at the same time; children learn about eating from those around them so if they see their carers or siblings enjoying the same food as them, they are more likely to try it. It is important that mealtimes are seen as a sociable activity to be enjoyed � If your child gets up from the table then calmly end the meal � there is always the next meal � After a main meal offer a small dessert such as fresh fruit and full fat yogurt, small cup cake and custard Have short mealtimes of up to 20 minutes How do I know when my child has had enough to eat? Let your child tell you when they've had enough � it is really important that you listen to their cues. � As when they were babies, they will start closing their mouth, trying to get down from the table, turn their head away, splay their hands or start spitting, shouting or crying, stop at this point � they are finished � If they say they have had enough to eat � try not to ask them to have a few more mouthfuls, you are teaching them to overeat. Respect their fullness � even if they have only have 1 mouthful Keep offering new food � it will take time before a new food is accepted and liked It can take a while before children will eat new foods � so long in fact that many parents give up! Children are often wary of trying new foods or foods they like that look slightly different e.g. different type of yogurt or packet of pitta bread. Children can take up to 15 tries (or even just looking at something) before they will like something new � for some it can take even longer. Offer regular meals and eat together as this helps children learn that food can be delicious and sociable What general advice is there for encouraging positive mealtimes? � Keep calm and don't rush � some days are better than others � Keep offering new foods � they will eventually try them � Children eat in colour � think of a rainbow when you are making their meals � Children like fun � so make their food look fun � Children like to help and want to please � involve them in the buying, preparing and cooking � Offer small portions and give your child lots of praise and attention when they finish it. You can then offer a second helping What texture should I expect my little one to eat? � Children who are weaned late during the first year of life may have missed some of the milestones for accepting new foods and textures, which can make moving on from smooth puree's harder (but not impossible) � Continue to offer your child lots of different kinds of foods, try not to get put off if they reject new foods If you are finding it difficult to get your little one to accept new textures speak to your child's team Children find sitting still very difficult and get bored quickly � Have short mealtimes of not more than 20 minutes or shorter if your child gets upset and does not want to eat � Use a stop watch on your phone or buy a 15 � 20 minutes sand timer � children like to watch the sand going down and it helps to put a limit on the length of mealtimes � Limit the amount of distractions at mealtimes e.g. electronic devices, television � chatting while you eat is good Mealtimes should be fun! Young children usually live to play, not eat. For many they would much rather be listening to a story or playing than sit down and eat. Therefore, it is important to make mealtimes fun and enjoyable, for the whole family! Don't enter into food battles � if they don't want to eat, don't bargain or bribe them You could try reading books with vegetable and fruit characters such as "mighty broccoli and cheeky cherry", this has been shown to increase young children's interest in tasting new foods. All children are unique � as is their appetite and how much they will eat 06 07 Don't enter into food battles � if they don't want to eat � don't bargain or bribe them Try not to enter into food battles with your little one � they will win! It is important to ensure you serve up child size portions � remember the size of their clenched fist; � If your delicious lovingly prepared mini dish of food is greeted with a "yuk � I am not eating that" � Respect your little ones decision with a "that's fine � you don't have to eat it... but you do have to sit here as it is dinnertime" � The family � even if it is just you and your little one then sit down to a meal � Respect them not eating anything or only eating the thing they like � Always offer a dessert � don't use dessert as a bribe as you are reinforcing the fact the main meal is so "yuk" that a bribe is needed to eat it Fussy eating is really common amongst young children and up to 40% of parents report their child has refused food at some point. Between 12 � 18 months of age, all young children develop "neophobia" � the fear of new food or familiar food offered in a different way. As fussy eating is such a common problem there are lots of tips and advice available � importantly: � Children like to eat with others and will often eat more in a group or when there is a relaxed family environment � Try to eat similar food at meals times to your little one e.g. fork mashed or squares of sandwich � Always, always make some part of the meal you know they will eat, then you know they won't go hungry � Eat with them at the same time � encouraging your child with smiles and positive sounds change or copy other children, so eating with others may not help them to accept new foods or textures � Some children may also have sensory issues and refuse to wear certain clothes or colours. They may also not like to get messy or sticky and dislike seeing people eating food they do not like � which can make them gag or vomit. For these children encourage messy play � This can be done with different kinds and textures of food � Shaving foam is also good fun for your child to put their hands in � Jelly is a great food to play with � wibbly and wobbly � Chocolate pudding on a chopping board for cars to drive through At mealtimes: � Be sensitive to what your child likes and dislikes If this is you: � It is easier said than done, but try to have a relaxed approach to mealtimes � Put the radio on and sing along or listen to a radio programme as it will distract you from the mealtime � Have something to eat at the same time, so your attention is not just on your child. They can also learn to enjoy their food by watching you enjoy it too choking risk children should be sitting whilst eating � Children should not have whole nuts under the age of 5 years � Other hard food, including Granola, should be ground into a finer crumb and not have any hard bits in it � it should also be mixed into food before serving � Always keep crumbed or hard food out of children's reach and always supervise snack or mealtimes � Sometimes doing a child first-aid course can help with any anxiety around mealtimes and choking risks. Ask your Health Visitor to find out what is available near home Most children love to get messy � however, some find it really stressful � so start slowly � outside of mealtimes � Try not to put really disliked food on the same plate as food which is liked � as some children will refuse the whole plate � Away from a mealtime offer tiny tastes of foods that your child might be willing to try � Offer your child different things to smell zest of lemon, herbs, melted chocolate � make a chart and together tick off the smells they like or don't like Children pick up on your non-verbal cues � if they feel you are tense about mealtimes � Don't worry if your child doesn't eat anything � sometimes children aren't hungry for their meals and this is normal � Invite a friend or family member to come and have a few meals with you � as having someone else to talk to can help � Have a picnic instead of eating at the table � you can have an indoor picnic if it is too cold to eat outside � Go out to a caf� and have a drink � offering your child food in a new environment can help My child is really fussy � what shall I do? For some parents feeding their baby has always been easy, but for others their little one's feeding journey has been really challenging � with vomiting, reflux and poor weight gain. As a result of these negative experiences associated with eating, some young children may have developed feeding difficulties or fussiness around food. Some children are fussier than others, but the good news is that with the right encouragement most children will have outgrown being fussy by 6 years of age. Most children love to get messy � however, some find it really stressful � so start slowly � outside of mealtimes � First start with general play with sand and water or paint � Play-doh, kinetic sand and painting are also good tactile games � Once they are comfortable with this take some dry uncooked pasta and place a top on top of the pasta for your child to pick up � Let them see you do it too � Once they are happy with this step, hide the toy in the dry pasta for them to find � Moving on to cool cooked pasta, hide the toy For children who need to gain weight � add nut butters to main meals Children have small tummies (about the size of their fist) so it is tricky to fit a lot in without either making them feel ill, or be sick. Examples of ways to get the most out of each mouthful are as follows; Snacking between meals does not suit all children as it can impact on their hunger and willingness to eat at a main meal. All children are different, so work out whether your child would prefer to have just 3 meals a day or 3 meals and one or two snacks. Snacks can be a useful back up if your child does not eat that well at mealtimes, but don't use snacks to replace main meals. Toddlers usually develop "neophobia", which simply means they don't like new foods � Change only one thing at a time � don't offer too many new foods at once, it can be overwhelming � Do not let new foods touch a favourite food as this can put them off their favourite food � Children who have very strong opinions about food are less likely to accept HELP: I feel really stressed about mealtimes! How can I relax? Our children know us really well. They read our body language and pick up on how tense we are through our faces and the way we sit or stand. For some parents, mealtimes are really stressful and even though they try to smile, their child senses something is wrong... I worry my child will choke � are there any foods I need be careful of? � Peel all fruit and vegetables. Cut round slippery foods length ways into quarters e.g. cherry tomatoes, grapes. As this is a 08 09 For children who need to catch up in terms of growth aim to provide; � Ages 1 � 3 years: an extra 200 � 300kcal, 7.5g protein per day � Ages 4 � 5 years: an extra 300 � 500kcal, 12.5g protein per day Table 1 can be used to plan ways in which to provide extra calories. It is important to use energy-nutrient dense foods e.g. nut butters. For example 6 teaspoons of peanut butter a day is almost 200kcal and 7.5g protein. We do not recommend the addition of extra oil or cream to food � if you have a heavy rich meal it can make you feel sick, children have the same feeling. Instead try to use a teaspoon of smooth nut butters, coconut cream, smooth plain cream cheese or a small pinch of grated cheese. Breakfast: � Add 1 � 2 teaspoons of smooth nut butter (almond, cashew, peanut) to warm porridge or � Toast with 1 � 2 teaspoons of nut butter and marmite or chocolate spread � Add 1 � 2 teaspoons of a nut butter to a home-made fruit smoothie � Add Marvelous nut dust (finely ground) to other breakfast options � mixing it in before serving Lunch and supper: � Offer protein at both main meals such as meat, boneless fish, chicken or beans/lentils with a starch (rice/ potatoes/pasta) and vegetables � add 1 � 2 teaspoons of a smooth nut butter or Marvelous nut dust � A small amount of grated cheese/ cream cheese can be added to mashed potato or meat dishes, instead of a smooth nut butter � Following a meal offer - Fruit or full cream yogurt - Full cream custard with a small cup cake - Rice pudding with 2 teaspoons of chocolate nut butter - Mashed avocado with toasted pistachio dust mixed into the avocado Eating veggies � children need to see you eating them too We all like sweet foods, so for many people veggies may not be their first choice of food. We should all eat 5 or more portions of fruit and vegetables a day. Some children really struggle with veggies, so here are some tried and tested tips; � Children need to see you enjoying veggies � so cook your favourites and eat them as a snack or with your meal � Most children 3 years and above like frozen peas � put a small amount in a pot and offer them whilst they are still frozen � Chop leafy veg such as kale and cabbage into really small bits � Cook leafy veggies with some chicken, pancetta or add a little gravy to give it a more savoury taste � Eat the same veggies as your children � Put mayo or tomato ketchup on salad � Don't insist they try it � all you can do is make it look yummy � Make up fun names � rocket man, pirate peas, beautiful butternut � Look for video clips of other children eating vegetables � Play with veggies � getting them to tear it, wash it, mash it � Take veggies selfies � Start with 1 teaspoon of a new veggie on their plate or side plate Continue with positive touch, massage and encouraging smiles � this all helps to reinforce positive messages about food. It is a good idea to start brushing your child's gums and teeth from when you see the first tooth. � Try not to let young children fall asleep with a bottle of milk in their mouth � offer milk before they go to bed, brushing their teeth afterwards � Use a toothpaste containing fluoride � it should have 1,350�1,500 parts per million (ppm) fluoride � Below the age of three years, children only need just a smear of toothpaste � Children aged 3 to 6 should use a peasized blob of toothpaste � Under the age of 7 years old you should brush your child's teeth for about two minutes twice a day: once just before bedtime and at least one other time during the day � Make tooth brushing as fun as possible by using an egg timer to time it for about two minutes � Don't let children run around with a toothbrush in their mouth, as they may have an accident and hurt themselves STEP 1 If your child is gagging or retching at new food on their plate, to begin with put a small amount e.g. 1 cooked carrot finger stick on a plate in the kitchen STEP 2 Encourage your children to be active � do activities as a family All children and young people should engage in `moderate to vigorous' physical activity for at least 60 minutes every day. You should also try to include some `light' activity and some `strength' activity.' It is important when doing sport that you exercise your whole body in a fun way! Why is it important to be active for at least 60 minutes each day? When they are able to look at it away from the table � put the new food on a plate in the middle of the table Don't comment on the food, just leave it there STEP 3 Once this has been accepted, move the plate closer to their plate � again don't comment or ask them to try it Make food fun Green soup can become "super hero" soup � add crispy croutons on top, serve it in little tea cups and just leave it for them to look at. If children see you eating something and enjoying it � they will eventually try it. Role playing about food outside of mealtimes, shopping games, helping with cooking such as passing vegetables is a good way of engaging children. Watching cooking programmes and talking about food, describing the smell and taste whilst you watch can help. Making colourful meal boxes � Pick a colourful Bento box/food container STEP 4 As they get more comfortable with the idea of a new food, then put a small amount on their plate e.g. 1 broccoli stem � they don't need to try it Brush your child's teeth at least twice per day � Helps keep our hearts and muscles healthy � Helps us keep a healthy weight � Improves bone health � Improves self-confidence and self-esteem � Develops new social skills and meet new people STEP 5 Once they are happy with the new food on their plate � ask them if they would pick it up and smell it Help teach your child how to brush their teeth properly � There are some fun clips on brushing children's teeth https://www.youtube. com/watch?v=kuLxz5IrZ6Y � Guide your child's hand so they can feel the correct movement � Use a mirror to help your child see exactly where the brush is cleaning their teeth STEP 6 After smelling, move to licking � then a small bite, they are allowed to spit it out � then to progress to swallow It can take weeks to get to this point � after a while the process will get easier and it will be quicker Make food fun � give dishes fun names... � Use colourful food picks to make a mealtime fun � Add edible cartoon eyes to food � Use a brightly coloured silicone muffin cup 10 11 Table 1: Foods which can be used for extra calories and protein Food item < 50 kcal 1 teaspoon chocolate spread 1 heaped teaspoon cream cheese 50�100 kcal 2 teaspoons smooth peanut butter Bacon � lean rasher Fruit smoothie 1 tablespoon Marvelous nut dust (see page 22) 100�150 kcal Egg, (1) scrambled with milk Chicken, drumstick Cubes of cheese 150�200 kcal Avocado, half 75g 183 1 Yogurt, full fat 175ml 180 7.7 60g 40g 45g 105 110 150 6.2 11 10 Meatball, small Milk, full cream Baked beans 60g 200ml 125g 125 125 116 16 6.4 6 10g 40g 150ml 15g 100 2.3 58 69 2.4 12.9 Egg, boiled Raisins � small box Banana Olives (cut in half lengthways) 60g 27g 100g 10 88 88 92 60 7.6 0.86 1.3 <0.5g 5g 10g 15 34 0.8 0.6 1 teaspoon peanut butter Cheese (pinch) 5g 10g 29 35 1.2 2 Table 2: Examples of exercise and the benefits Amount Energy (kcal) Protein (g) Exercise Light Amount Energy (kcal) Protein (g) Food item What is it and how does it help your body? This won't make you hot or sweaty. It gets your body moving and is a great way to get into doing more physical activity if at the moment you don't do very much. This will make you feel warmer and breathe harder. You should feel your heart beating faster, but still be able to carry on a conversation. This exercise is good for your heart. Examples � Walking � Playground activities Moderate � � � � � � � � � � � � � � � � � Walking Playground activities Slow swimming or playing in the water Riding a scooter Skateboarding Roller blading Riding a bike on flat ground or with very few hills Riding a horse Running or playing running games such as `stuck in the mud' Swimming Team sports such as Hockey / Basketball / Football Fast cycling or on hilly terrain Swinging on playground equipment Hopping and skipping Sports such as gymnastics or tennis Playground games such as `tug of war' Rock, rope or tree climbing Vigorous * This will make you out of breath and possibly red in the face, making it more difficult to carry on a conversation. This type of exercise is good for your heart. Strength This helps to make your bones and muscles strong. * if you are not sure check with your health care team before you do anything that is very vigorous HELP: none of this advice is working If you are finding any aspect of introducing food difficult or your little one is showing signs of not wanting to eat at all � don't suffer in silence � your child's team can help. 12 13 Food & feeding advice for young children Food and Feeding Advice Type of food to offer If you are making food at home, try some of our recipes in this book. From 12�18 months of age � Continue with your child's usual milk or a nutrient energy dense infant formula around 12 � 16oz � Main meals should include protein e.g. chicken, fish, beans, lentils, meat along with veggies and starch e.g. potato, rice, pasta � If your child needs to gain weight add 2 teaspoons of smooth nut butter to each meal including porridge at breakfast � Keep offering new foods � although it should not touch any favourite food � At this age children start not to need as many calories to gain weight as they did when they were babies � Eats ground, mashed, or chopped table foods (including soft pieces of meat chopped cut up very small) by 15 months � All finger food should still be soft, must fit easily into your child's hand and be just the right size to easily fit into your child's mouth � Know when your child has had enough � signs include starting to play with food, tries to get out of their high chair From 19�24 months of age � Continue with your child's usual milk or a nutrient energy dense infant formula around 10 � 12 oz � Main meals should include protein e.g. chicken, fish, beans, lentils, meat along with veggies and starch e.g. potato, rice, pasta � If your child needs to gain weight add 2-3 teaspoons of smooth nut butter to each meal including porridge at breakfast � Keep offering new foods � although it should not touch any favourite food � Food refusal of favourite or new foods is common around this age � your child will start to show clear likes and dislikes � Chopped texture, small soft pieces including adult style foods � Offer foods with a firmer texture to promote chewing skills � At this age children chew with up/ down and side to side action � All finger food must fit easily into your child's hand and be just the right size to easily fit into your child's mouth � Know when your child has had enough � signs include starting to play with food, tries to get down from the table � Encourage sitting at the table � children should not be walking/running when eating � Encourage the use of small child size utensils e.g. fork, spoon � Is able to feed themselves using a spoon � with less spills � Able to keep their mouth closed when chewing and swallowing � Start to stab food with a fork and get it to the mouth � Should have adult supervision at meal/ snack times � Some young children start to eat very fast � encourage them to eat slowly chewing their food � Mealtimes should last for up to 20 minutes From 2 years to 5 years of age � Continue with your child's usual milk or a nutrient energy dense infant formula around 10 � 12oz � Main meals should include protein e.g. chicken, fish, beans, lentils, meat along with veggies and starch e.g. potato, rice, pasta � If your child needs to gain weight add 2�4 teaspoons of smooth nut butter to each meal including porridge at breakfast � Keep offering new foods � although it should not touch any favourite foods � May become a "fussy eater" refusing foods that were previously liked � By three years of age your child should be able to eat the same foods as the rest of the family � All finger food must fit easily into your child's hand and be just the right size to easily fit into your child's mouth � Know when your child has had enough � signs include starting to play with food, tries to get down from the table Food and Feeding Advice Finger foods From 12�18 months of age � The best types of foods to start off with are ones that dissolve easily e.g. sweetcorn puffs. � Dissolving foods melt evenly in the mouth without leaving lumps e.g. wotsits � These types of food help with chewing skills as your little one needs enough skill to be able to hold the food in the mouth until it melts � Other good finger foods to then move onto are steamed well cooked carrots sticks, banana, avocado, soft pear, soft flaky fish, toast finger, pasta shells All finger food should be soft, easily fit into your child's hand and be just the right size to easily fit into their mouth. Cooked soft finger shaped foods are helpful rather than round shapes. From 19�24 months of age � Even with finger foods children should be sat down � they should never eat and walk/run � As your child's skills increase they will be able to manage different types of soft food � It is sometimes useful to offer these foods as in between meals snacks so you and your little one can enjoy them exploring new foods and textures together All finger food should be soft, easily fit into your child's hand and be just the right size to easily fit into their mouth. Cooked soft finger shaped foods are helpful rather than round shapes. From 2 years to 5 years of age � Always sit with your children when they are eating any food including finger foods � As a snack offer soft cooked vegetables and dips in small pots � It is sometimes useful to offer these foods as in between meals snacks so you and your little one can enjoy them exploring new foods and textures together All finger food should be soft, easily fit into your child's hand and be just the right size to easily fit into their mouth. Cooked soft finger shaped foods are helpful rather than round shapes. Textures Choking hazards Mealtimes � Should sit on a high chair � Is able to feed themselves using a spoon � although expect some food to drop off � It is common for a little bit of food or saliva to still fall out of their mouth � Encourage self feeding � Should have adult supervision � Offer drinks from a sippy cup � Should have adult supervision at meal/ snack times � Mealtimes should last for up to 20 minutes � Encourage sitting at the table � children should not be walking/running when eating � Your child will have definite food likes and dislikes and may refuse certain foods � Continue to encourage new foods � which may take 15 tries before being accepted � Drinks from a cup or beaker � Encourage independent feeding using small child size utensils e.g. fork, spoon � A spoon and fork should be held between the fingers palm up. Introduce a child size knife for practice � Should have adult supervision at meal/ snack times � encourage slow eating � Mealtimes should last for up to 20 minutes � Some types of food are a choking hazard and should be avoided in babies and young children � This list may not included everything � so it is important that you sit with your little one at each meal & snack time � Young children should be encouraged to sit down and eat rather than run around � Hard lumps of any size should be avoided � Raw vegetables are often hard � so offer soft cooked sticks e.g. carrot, courgette and celery � Hard pieces of raw fruit such as apple and pear should not be given � Avoid slippery foods such as pieces of canned fruit � cut them up into small pieces or mashed e.g. sweet corn kernels; � Hard lumps of any size should be avoided in children under the age of 3 years, as they require very developed chewing skills. � Raw vegetables, hard or stringy meat, hard peas and beans, hard dried fruit, toasted or hard sugar syrup coated cereals and `granola' type products and hard crisp or chip products are all examples of foods that should be avoided. � For toddler and young children all finger foods should be cut in short thin stick e.g. lengthways rather than then being round in shape, as this reduces the risk of choking - Mini sausages / mini scotch egg balls - Cut whole grapes, berries, cherries, melon balls, cherry / plum tomatoes lengthways into quarters - Cut orange / satsuma segments into quarters � take the pips out - Chunks of fish flaked should be checked for bones * Suggested feeding times: 8-9 am, 11-1 pm, 4-5pm with milk before or with breakfast and just before bedtime (ensure you brush you little children's teeth at least twice a day e.g. after breakfast and before bed) 14 15 Simple week meal planner From 12 months of age Day With or before breakfast Child's usual milk Breakfast Mid morning Lunch Evening meal Before bed Child's usual milk MONDAY Porridge with milk, peaches & granola (ground into a fine crumb) Vegetable sticks & hummus Mini packed lunch* Meat, chicken or fish based ready prepared child's food Fruit pot Meat, chicken or fish based ready prepared child's food Yogurt Meat, chicken or fish based ready prepared child's food Oat based pudding Meat, chicken or fish based ready prepared child's food Fruit pot Meat, chicken or fish based ready prepared child's food Fruit pot Meat, chicken or fish based ready prepared child's food Oat based pudding Meat, chicken or fish based ready prepared child's food Custard TUESDAY Child's usual milk Toast with smooth peanut butter & banana Porridge with milk, peaches & ground almonds Toast with smooth almond butter & jam Grated cheese, cherry tomatoes & grapes Asparagus wrapped in ham Mini packed lunch* Child's usual milk WEDNESDAY Child's usual milk Mini packed lunch* Child's usual milk THURSDAY Child's usual milk Broccoli, olives & breadsticks Mini packed lunch* Child's usual milk FRIDAY Child's usual milk Porridge with milk & dates, prunes Baby sweetcorn, mange tout & avocado Baby sweetcorn, mange tout & avocado Vegetable sticks & mashed avocado Mini packed lunch* Child's usual milk SATURDAY Child's usual milk Toast with smooth peanut butter & marmite Porridge with milk, raspberry & ground almonds Mini packed lunch* Child's usual milk SUNDAY Child's usual milk Mini packed lunch* Child's usual milk NOTES: A. Children between the ages of 1 and 3 need to have around 350mg of calcium a day. About 300ml of milk will provide this. Non-dairy calcium enriched drinks may also be used. B. All round or slippery foods e.g. olives, cherry tomatoes, grapes, cucumber should be cut lengthways into thirds or quarters. Where possible they should also be peeled. C. Children should eat sitting down and be supervised at all times whilst eating D. Hard foods such as carrots should be lightly cooked E. *Mini packed lunch � see the recipes for lunch boxes below � these can be adapted for the age of your child and what textures of food they can eat e.g. fork mashed F. If your child needs to gain weight add: 1 � 2 teaspoons of Marvelous nut dust or smooth peanut butter to each main meal 16 17 Shopping list For the recipes you can buy fresh, frozen or tinned fruit and vegetables. All of these ingredients are available in budget as well as other supermarkets. Fr ui t & Ve gg ies � Frozen pe as ixe d pe pp ers � Frozen /f re sh m rn � Frozen swee t co rrot s � Frozen /f re sh ca sh, ge m sq ua sh � Bu tter nu t sq ua swee t po tato � Swee t po tato, ble Ka le, ca bb age, � Al l gree n ve ge ta urge tte, gree n Br us se l Spro uts, co ga r sn ap pe as, be ans, cucum be r, su li, runner be ans m ange to ut, broc co pa rs ni ps � Swede, tu rn ip s, s , pi ne apple , ch er rie � Banana, m ango es ache s, ne ctar in (withou t stones), pe � Av oc ado spbe rr ies � Frozen /f re sh ra ue be rr ies � Frozen /f re sh bl ango � Frozen /f re sh m in ju ice � Ti nned pe ache s ju ice � Ti nned pr unes in ric ot s � Re ad y to eat ap � Su lta na s Nut bu tters (n o adde d suga r va rie tie s) � Smoo th pe an ut bu tter � Smoo th ca sh ew bu tter � Smoo th almon d bu tter Pu ls es & grai ns � Ch ic kp ea, be an or gram flo ur � Ti nned ch ic kp ea s � Le nt ils � gree n an d re d � Grou nd almon ds � Q ui no a Oi ls � Co co nu t crea m � Ol ive oi l Fi sh & meat � Whi te or oi ly fish � Lam b � Be ef � Ch ic ke n He rb s & sp ice s in t � Frozen /f re sh m ri an de r � Frozen /f re sh co nger � Frozen /f re sh gi ic � Grou nd tu rmer namon � Grou nd cin 18 19 Recipes � Breakfasts � Power energy balls � Warming soups � Bento boxes � Family favourites � Sweet things 20 21 Marvelous nut dust This Marvelous nut mix is bursting with goodness � nutritious nuts are rich in protein, fats, energy and micronutrients. For those who are trying to make the most out of every mouthful use the Marvelous nut dust on cereal in the morning, an added crunch to a pitta pocket or sprinkled on pasta and rice dishes to provide an unexpected flavour burst. The Marvelous nut dust can be spiced up with some dried chili flakes. Granola Ingredients � � � � � 100g Pistachios 100g Almonds 100g Pecan nuts 100g Walnuts 100g Brazil nuts Other kinds of nuts that can be included: � � � � Macadamia Hazelnuts Chestnuts Peanuts Ingredients � � � � � � 300g oats 200g chopped nuts (almonds, pistachio, hazelnuts) 50g dried apricots 45g (3 tablespoons) golden syrup 2 tablespoons of olive oil � teaspoon vanilla extract Method 1. Where possible buy ground nuts e.g. ground almonds 2. For whole nuts, use a hand held blender or mini food processor to blitz the nuts into a fine dust. For larger nuts such as Brazils cut into pieces before blitzing 3. Store in an airtight container Method 1. Heat the oven to 200oC / 180oC fan / gas mark 6 2. Add all of the ingredients to a mixing bowl and stir until everything is covered in golden syrup/oil � it may be easier to mix using your hands 3. Spread the mixture in a thin layer on a baking sheet (use greaseproof paper) 4. Bake for 10 minutes until lightly toasted 5. Cool before storing then crumble into small pieces 6. Store in an airtight container for up to 2 weeks Nutrition content per 100g 655 kcal / 14.5g protein Serving suggestion 1 tablespoon = 15g � 100kcal / 2.3 protein Serving suggestion Important to note: � For children under the age of 5, nut dust should be ground into a fine crumb with no hard lumps or chunks of nuts which may be a choking hazards � As there is a choking risk with crumbs, it is also important the nut dust is mixed well into food and not offered only as dust � The nut dust should be kept in a sealed container out of the reach of young children � If your child has a nut allergy do not use the Marvelous nut dust in food. If there is a history of nut allergies in the family and you are unsure if your child can tolerate nuts, please discuss nut introduction with your Health Care Professional. Add 2 � 3 tbsp to your usual cereal and milk Important to note: � For children under the age of 5, Granola is not suitable and should be ground into a fine crumb with no hard lumps or chunks which may be a choking hazards � As there is a choking risk with fine crumbs, it is also important the granola crumb is mixed well into food. � The granola should be kept in a sealed container out of the reach of young children. 22 23 Breakfast porridge Ingredients � 50g rolled oats � 300ml full cream milk or your child's usual milk � Pinch of salt Prunes, dates & ground almonds Ingredients � 150g tinned prunes in juice � 30g ready to eat apricots � 20g (2 tablespoons) ground almonds Method 1. Place the tinned prunes and ready to eat apricots (approximately 8) with the prune juice in a pan and simmer on a low heat for 5 minutes or until the fruit is soft 2. Add in 20g or 2 tablespoons of ground almonds 3. Using a stick blender, puree ingredients until smooth 4. Portion into ice cube trays Method 1. Add the oats and full cream milk to a pan 2. Place on a medium heat 3. As the mixture starts to bubble, stir well 4. Once it is thick, take off the heat and serve in a bowl 5. Add your favourite topping (from the following pages) and eat whilst warm Serving suggestion 2 � 3 cubes added to your porridge Important to note: � Instant porridge can be used following manufacturer's instructions, rather than making your own � If you don't like hot porridges you can add one more of the toppings below to your usual cereal with milk, to which you can add a dollop of yogurt 24 25 Peaches, sultanas & ground almonds Ingredients � 150g tinned peaches in juice � 30g sultanas � 40g (4 tablespoons) ground almonds Mango & almond butter Ingredients � 200g fresh mango � 30g (6 level teaspoons) almond butter Method 1. Peel and chop the fresh mango into chunks 2. Place in a bowl along with 30g smooth almond butter (6 level teaspoons) 3. Using a stick blender, puree until smooth 4. Portion into ice cube trays Method 1. Place the tinned peaches, juice and sultanas in a pan and simmer on a low heat for 5 minutes 2. Add in 40g or 4 tablespoons of ground almonds 3. Using a stick blender, puree until smooth 4. Portion into ice cube trays Serving suggestion (both) Serving suggestion 2 � 3 cubes added to your porridge 2 � 3 cubes added to your porridge Raspberry, banana & almonds Ingredients � 200g fresh or frozen raspberries � 200g banana � 50g ground almonds Method 1. Peel and chop the banana into chunks 2. Put the raspberries into a bowl along with the banana and ground almonds 3. Using a stick blender, puree until smooth 4. If the puree is a little thick add a splash of almond milk/whole milk 5. Portion into ice cube trays 26 27 POWER ENERGY BALLS Date & apricot power balls These are great for little mouths as between meal snacks or as part of a dessert with some fresh fruit. Dino soup Ingredients � � � � � � � WARMING SOUPS Method � � � � � 500ml water 150ml single cream 1 tablespoon of olive oil Salt and pepper Home made croutons e.g. soft bread cut into small cubes 1. Heat the oil in a large saucepan over a medium heat 2. Add in the finely chopped celery, onion and cook until soft 3. Add in the broccoli, courgettes, peas, basil, chicken stock and water 4. Bring to the boil and cook until the vegetables are tender (5 minutes) 5. Using a stick blender carefully blend until the soup is smooth 6. Add in the single cream and seasoning 7. Serve the soup in bowls or teacups, sprinkle with croutons � this makes a great between meal snack Ingredients � 250g walnuts or ground almonds, or other nut/seed of choice � 250g shredded unsweetened coconut � 320g soft Medjool dates, pitted � 2 tablespoons sunflower oil � � teaspoon sea salt � 1 teaspoon vanilla extract 400g broccoli 400g frozen peas 400g courgettes 2 sticks of celery 2 onions finely chopped Small packet of basil 500ml chicken stock Important to note: � For children between the ages of 1 � 3 years of age, offer small cubes of soft bread dipped in the soup instead of ready to eat croutons which are too are too hard for young children and may pose a choking risk. Method 1. Roughly chop the dates 2. Keep � of the coconut to one side in a bowl for rolling the balls in, to coat them in coconut 3. Put all of the ingredients into a bowl. Using a hand held whisk or food processor blitz until it is a smooth paste 4. Take a teaspoon or tablespoon of mixture (depending on the size of ball you want) and roll into a ball 5. Roll the ball in the coconut 6. Place on parchment or greaseproof paper 7. When finished rolling the balls, put them in a greaseproof paper lined container and put them in the freezer 8. Pop a few in a snack box or as a dessert � can be eaten frozen! 28 29 Super hero orange soup Ingredients � � � � � � � � 800g butternut squash 400g sweet potatoes 2 sticks of celery 2 onions finely chopped Small packet of coriander 500ml chicken stock 500ml water 50ml orange juice � 150ml coconut cream � 2 tablespoons nut butter � Small pinch of chili (optional) � 1 tablespoon of olive oil � Salt and pepper � Home made croutons e.g. soft bread cut into small cubes WARMING SOUPS Bento boxes Method 1. Heat the oil in a large saucepan over a medium heat 2. Add in the finely chopped celery, onion and cook until soft 3. Add in the butternut squash, basil, chicken stock, orange juice, coconut cream, chili (optional), seasoning and water 4. Bring to the boil and cook until the vegetables are tender (25 � 30 minutes) 5. Using a stick blender carefully blend until the soup is smooth 6. Serve the soup in bowls or teacups, sprinkle with home-made croutons � this makes a great in between meal snack Important to note: � Use home made croutons using small cubes of soft bread. Ready to eat croutons are too hard for young children and may pose a choking risk. 30 31 BENTO BOXES Fusilli, ham, peas & cheese Ingredients � � � � � � Photo 1 Ham & cheese pitta & fresh fruit Ingredients � Small toasted wholemeal pitta, cut into strips � Handful of grated cheese � Slice of ham � Olives � Red pepper � Passion fruit, figs, grapes (or other seasonal fruit) BENTO BOXES � Edamame or green beans 50g fusilli � Pomegranate seeds 1�2 slices of ham � Grapes 25g frozen peas � Pear 30g grated cheese Carrots ribbons 1 teaspoon Marvelous nut dust Method 1. Cook some fusilli in boiling water until al dente (has a bite to it), add the peas and cook for a further 1 � 2 minutes 2. Whilst the pasta is cooking shred the ham and grate the cheese 3. To the hot drained pasta add the ham, Marvelous nut dust and grated cheese mixing well 4. Using a vegetable peeler make some carrot ribbons 5. Take 10 � 15 edamame beans and thread onto a food pick or plastic skewer 6. Cut the fruit lengthways, add a few pomegranate seeds 7. Put into the bento box Photo 3 Photo 2 Method 1. Arrange the pitta strips in the Bento box with the ham and grated cheese 2. Put the olives, cut length ways in half or quarters with the lightly steamed red pepper pieces 3. Arrange the fresh fruit in the other side of the Bento box, peel and cut grapes length ways in half or quarters 4. Use a child size soft teaspoon to scoop the inside of a fig or passion fruit (Photo 3) Photo 4 Important to note: � All vegetable and fruit should be washed before eating � Lightly steam hard vegetables � All vegetables and fruit should be cut length ways into small pieces, and some will need to be peeled � Recipes can be change to inclu
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Papers Trust Board - 29 November 2022

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

Press release: Southampton eye experts trial 'buzzing belt' to help patients with sight loss

Description: Eye experts in Southampton are trialling a discreet 'buzzing belt' that can help people with sight loss find their way around.
Url: /AboutTheTrust/Newsandpublications/Latestnews/2019/December/Press-release-Southampton-eye-experts-trial-'buzzing-belt'-to-help-patients-with-sight-loss.aspx

Using water for labour and birth - patient information

Description: We have given you this factsheet because you may be considering using water during the labour and birth of your baby.
Url: /Media/UHS-website-2019/Patientinformation/Pregnancyandbirth/Using-water-for-labour-and-birth-1681-PIL.pdf

Signs that your baby may be unwell - patient information

Description: This factsheet provides information about what signs to look out for that show your baby may be unwell and when to
Url: /Media/UHS-website-2019/Patientinformation/Pregnancyandbirth/Signs-that-your-baby-may-be-unwell-587-PIL.pdf

Cyclopentolate eye drops for children - patient information

Description: This factsheet contains information about having cyclopentolate eye drops as part of your child's sight test.
Url: /Media/UHS-website-2019/Patientinformation/Eyes/Childrens-eyes/Cyclopentolate-eye-drops-for-children-1969-PIL.pdf

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