This section includes all the pledges we have made as an organisation, formal statements, compliance documents and reports on things like finances and staffing.


Bribery Act 2010 - statement published December 2011

Eliminating Mixed Sex Accommodation (also known as Delivering Same Sex Accommodation)

Sheffield Health and Social Care NHS Foundation Trust is pleased to confirm that it is compliant with the Government’s requirement to eliminate mixed-sex accommodation, except when it is in the service user’s overall best interest, or reflects their personal choice.

The Trust has the necessary facilities, resources and culture to ensure that service users who are admitted to its hospitals will only share the room where they sleep with members of the same sex, and same-sex toilets and bathrooms will be close to their bed area.

Sharing with members of the opposite sex will only happen when clinically necessary, for example, where service users need specialist equipment or when service users actively choose to share.

For those service users who sleep in shared spaces with people of the same sex we will do everything possible to ensure their dignity is respected and they have adequate privacy. Our reconfiguration, once completed, will remove all shared facilities.

If the Trust’s care should fall short of the required standard, this will be reported.

You can view our latest compliance statement by clicking here.

Formulary statement

Prescribing medicines and the choice of medication used within the Trust is based on the individual clinical needs of our service users. Any decisions on prescribing are made in line with National Institute for Clinical Excellence (NICE) guidance.

Medicines that are not seen as being cost effective to be made routinely available are classed as non-approved for use within the Trust. Unless NICE approved, all new psychiatric medicines are classed as non-approved unless approved by the Medicines Optimisation Committee. Have a look at our formulary statement.

Modern slavery statement

Modern slavery and human trafficking statement for the financial year ending 31 March 2023

This statement is made in pursuant to section 54 of the Modern Slavery Act 2015 and sets out the steps that Sheffield Health and Social Care NHS Foundation Trust has taken and continues to take to ensure that modern slavery or human trafficking is not taking place within our business or supply chain.

The definition for offences covered by the Modern Slavery Act 2015 can be found here.

We take a zero tolerance approach to Modern Slavery and Human Trafficking and have taken a number of steps to ensure that it does not take place in any part of our supply chains and within our own business.

Any identified concerns regarding Modern Slavery and Human Trafficking are escalated as part of the organisational safeguarding process working in conjunction with our partner agencies.

SHSC has taken the following action in accordance with the Home Office statutory guidance:

a) The organisation’s structure, its business and its supply chains

  • Adhering to the National NHS Employment Checks / Standards (This includes employees UK address, right to work in the UK and suitable references).
  • Continuing to follow NHS Agenda for Change terms and conditions to ensure that staff receive fair pay rates and contractual terms.
  • Ensuring that Agency staff are procured through approved frameworks and put internal systems in place to check that appropriate pre-employment clearance has been obtained for agency staff.
  • Ensuring that International recruitment takes place under the Code of Practice for International Recruitment (updated March 2023) and the Code of Practice for the international recruitment of health and social care personnel in England – Gov.UK (

b) Its policies in relation to slavery and human trafficking

  • Maintaining our policies and systems to report of concerns including Freedom to Speak Up and whistleblowing; and in respect of safeguarding, volunteering international recruitment and procurement.

c) Its due diligence processes in relation to slavery and human trafficking in its business and supply chains

  • Continuing to review of all safeguarding referrals via our incident reporting system and sharing data at our Safeguarding Assurance Committee.
  • Continuing to provide assurance from the Corporate Safeguarding Team to the Safeguarding Assurance Committee, Quality Assurance Committee and Sheffield Children and Adults Safeguarding Partnerships that the SHSC Safeguarding Adult Policy and South Yorkshire Safeguarding Adults Procedures are fully implemented.
  • Working in partnership with multi-agency partners leading on this agenda in South Yorkshire and ensuring that we are represented on these committees.
  • Working in partnership with sector partners on the approach to international recruitment.

d) The parts of its business and supply chains where there is a risk of slavery and human trafficking taking place, and the steps it has taken to assess and manage that risk and e) its effectiveness in ensuring that slavery and human trafficking is not taking place in its business or supply chains, measured against such performance indicators as it considers appropriate

  • Building long standing relationships with our suppliers and making clear our expectations of business behaviour. Ensuring that with regard to the supply chain that the majority of our purchases utilise existing supply contracts or frameworks which have been negotiated under the NHS standard terms and conditions of contract, which all have the requirement for suppliers to have modern slavery and human trafficking policies and processes in place. We maintain professional practices relating to procurement and supply and ensure that procurement staff attend regular training on changes to procurement legislation. All suppliers are requested to confirm their compliance with the provisions of the Modern Slavery Act (2015), through agreement of purchase orders and tender specifications.
  • Participating in the multi-agency Sheffield Adult Safeguarding Partnership and its associated sub-groups to support the South Yorkshire Safeguarding Adult Procedures, including links to the referral process for adults at risk in our Safeguarding Adults Policy.
  • Work in partnership with statutory and voluntary agencies across the Integrated Care System who lead on this agenda in South Yorkshire and ensure that SHSC is represented at relevant groups. 
  • As an NHS organisation, SHSC staff are not a designated first responder organisation. Only organisations listed as designated first responders can make referrals to the National Referral Mechanism (NRM). The list of referrers is on the link below. If SHSC staff have a concern about a person being subject to Modern Slavery, we have a responsibility to complete a safeguarding concern and refer to the Local Authority requesting that they report to the NRM. The Duty to Notify is also only for first responders but can be used when an adult does not consent. Further information can be found here.

f) The training about slavery and human trafficking available to its staff

  • Modern Slavery and Human Trafficking is available to staff, including the board of directors and is included within SHSC Level 3 safeguarding adult training.

Infection control

The Trust undertakes to ensure that it complies with ‘The Health Act 2008: Code of Practice for the Prevention and Control of Health and Adult Social Care on the Prevention and Control of Infections’ and is committed to reducing the risk of acquiring an infection to all individuals either in receipt of our care or through its provision.

This is to be achieved through multiple methods, with the aim to provide safe and clean care to benefit our service users and the wider health community.

Details of how this is being achieved can be found in our Infection Prevention and Control Annual Report 2020-21 here.

NHS Improvement Provider Licence

Our Board of Directors approved the Trust’s self-certification against the NHS Improvement Provider Licence on 22 June 2022.

Our response to the Francis Report published August 2013

We were appalled by the failings in care that took place at Mid-Staffordshire NHS Trust and also at Winterbourne View.

The Francis Inquiry report was published in February 2013 and examined the causes of the failings in care, making a series of recommendations.

Our culture is very different from those organisations. We have a legacy of service user involvement throughout the organisation; our staff are skilled, committed and motivated; clinicians and managers share leadership for improving quality and managing resources and we have a strong reputation for partnership working.

But we are not complacent. We operate in the same context and are subject to the same external pressures that contributed to the failings in those organisations and these are difficult times. Delivering high quality health and social care is becoming more complex and more challenging. Demand for services is increasing and we are currently operating in an environment of reduced public sector spending. Delivering high quality care in this environment is a challenge we are determined to meet.

We have a culture in which, should poor care take place, it is recognised and reported and so we do know that we have instances when care is not at the standard we would wish for our friends or families. We are therefore keen to learn whatever lessons we can from such instances to improve the quality of what we do.

We have taken this opportunity to revitalise our commitment that the people who use our services are at the heart of everything we do.

In addition to the above we also provided a formal response to it

Patient Led Assessment of the Care Environment (PLACE)

The Patient Led Assessment of the Care Environment (PLACE) is an annual self-assessment process for assessing the quality of the hospital environment.

PLACE applies to all hospitals delivering NHS-funded care that provide home-like accommodation.

The scheme is a voluntary process that we have chosen to be part of.

PLACE assessments examine five key areas of our services:

  • Cleanliness
  • Food and hydration
  • Privacy
  • Dignity and wellbeing
  • Condition, appearance and maintenance

It focuses on the environment in which care is provided and does not consider clinical care provision or staff behaviours. It only extends to areas accessible to patients and the public.

Our service users play an important role in carrying out the assessments. At least half of the people on an assessment team must be service users with the remaining places filled by Trust staff representatives.

Both patient and staff representatives are trained in the assessment process.

Every Trust that participates in PLACE is required to publish its results and an improvement plan explaining how we intend to use the results to make improvements.

Our results

Below you can find the results and action plan from our inspections since they started in 2017:


Prevent is the name given to the Government’s counter terrorism strategy and its aim is to stop people becoming terrorists or supporting terrorism.

The strategy promotes collaboration and co-operation among public service organisations including the NHS.

As part of the strategy we’re working to ensure our service users, staff, carers, family and members of the public are protected from any risk they may face.

If you have concerns about an individual or come across material that you think needs to be reporting you can visit the Home Office website.


The abuse of children and vulnerable adults can have a devastating and life-long effect on all its victims, including family members and carers and we are committed to preventing and identifying any abuse of children, young people and vulnerable adults and work closely with our Local Authority colleagues.

Like all public sector organisations we have a legal duty to protect children and vulnerable adults from harm wherever possible.

The Trust achieves this through risk assessment, risk management, staff training and supervision processes. We also work in partnership with other agencies through the use of approved procedures to refer and investigate known or suspected individuals as required.

All Trust employees are trained to recognise the signs of abuse and know how to report any concerns they may have.

You can take a look at our Safeguarding Annual Report 2022-2023 here

Security - hold to account

Our committed, caring and dedicated staff are our most valuable asset.

We are committed to protecting our staff from violence, harassment and abuse at work.  If such incidents occur we encourage service users, visitors and staff to report them immediately. 

There is also a ‘zero tolerance’ attitude towards such behaviours within the Trust and we will take action and, where appropriate, work with the police to bring those responsible to justice.

Our service users, visitors and staff deserve to work and be treated in a safe, calm and healthy environment. We will safeguard our property and assets from theft or criminal damage. We will consider taking action against anyone who deliberately damages Trust equipment or property.

Please help us to ensure that Sheffield Health and Social Care NHS Foundation Trust remains a safe environment for everyone.

The Armed Forces Covenant

On 19 January 2016 we signed the Armed Forces Corporate Covenant. The covenant is a commitment to support current and former members of the armed forces.

Our signed statement is available here.

We are proud to support the key principles of the covenant - that no member of the armed forces should face disadvantage accessing public services compared to anyone else, and that in some circumstances, special treatment may be appropriate especially for the injured or bereaved.

As a Bronze Award holder for the Defence Employer Recognition Scheme we aim to demonstrate our support for the armed forces community. 

We also recognise and value the experience and transferable skills that members of the armed forces community bring to the NHS, and are positive about recruiting service leavers, reservists, veterans and their families to the Trust. 

Veterans Aware Accreditation 

The Trust is currently working towards registering for the Bronze Veteran Aware Accreditation award. We want to show our commitment to support armed service veterans, reservists and their families.  

The Veteran Aware Accreditation reflects an NHS Trust's commitment to deliver the best healthcare and support to veterans and their families. We are signed up to the Veterans Covenant and Healthcare Alliance (VCHA) and as part of that we need to show how we are meeting eight specific standards. This includes making pledges around four key areas including:

1. Having ways to identify veterans coming into clinical services to make sure they receive appropriate care 
2. Training and educating our staff on needs of veterans 
3. Supporting the armed forces community as an employer 
4. Having clearly designated senior leaders to represent veterans (also know as veterans champion Dyad). 

Neil Robertson, director of operations and transformation, holds the responsibility for the veterans accreditation as the senior responsible officer and clinical director Linda Wilkinson holds the responsibility as the clinical Dyad champion.  

We are planning on submitting our application to become a Bronze level accredited veteran aware organisation in October 2023. 

If you are interested in being involved or finding out more about the work please contact Natasha Keen (Project Officer) Natasha.Keen@shsc.nhs uk or 

Trade Union Facility Time

On 01 April 2017, the Trade Union (Facility Time Publication Requirements) Regulations 2017 came into force.

The regulations mean the Trust collects and publishes information on the amount and cost of ‘facility time’ for the organisation.

‘Facility time’ is where an employee is given paid or unpaid time off from their normal role to carry out trade union duties and activities as a trade union representative.

There is a statutory entitlement to reasonable paid time off for carrying out trade union duties. 

There is no statutory entitlement to paid time off for undertaking trade union activities. 

The data for the reporting year 1 April 2020 to 31 March 2021 is shown below.

Relevant union officials

What was the total number of your employees who were relevant union officials during the relevant period?

Number of employees who were relevant union officials during the relevant period - 19
Full time equivalent employee number for the Trust –18.6

Percentage of time spent on facility time

How many of your employees who were relevant union officials employed during the relevant period spent a) 0%, b) 1%-50%, c) 51%-99% or d) 100% of their working hours on facility time?

0% - 4
1-50% - 11
51-99% - 4
100% - 0

Percentage of pay bill spent on facility time

Provide the figures requested in the first column of the table below to determine the percentage of your total pay bill spent on paying employees who were relevant union officials for facility time during the relevant period.

Provide the total cost of facility time - £156,319
Provide the total pay bill - £116,623,000
Provide the percentage of the total pay bill spent on facility time, calculated as (total cost of facility time divided by total pay bill) x 100 - 0.13%

Paid trade union activities

As a percentage of total paid facility time hours, how many hours were spent by employees who were relevant union officials during the relevant period on paid trade union activities?

Time spent on paid trade union activities as a percentage of total paid facility time hours calculated as:(total hours spent on paid trade union activities (JCF,JPG,AFC) by relevant union officials during the relevant period ÷ total paid facility time hours) x 100 - 3.56%

Hours spent on paid facility time - 6,845.5 hours
Hours spent on paid trade union activities - 244 hours

Use of force

The Trust's responsible person for use of force is Salli Midgley, Director of Quality.

We train our staff in RESPECT de-escalation and skills and the programme is accredited by the Restraint Reduction Network as per our NHS England contractual requirements.

Every year we will publish a report on the use of force within the Trust:

Our Use of Force Policy can be found here.

Any queries about the Use of Force Act implementation should be directed to

Trans and non-binary inclusion statement

At Sheffield Health and Social Care NHS Foundation Trust we are proud of our values and of our commitment to live these in our day-to-day lives and work.

We are aware that many trans and non-binary people continue to struggle with the impact of distressing comments and behaviours in many areas of their lives.

We have chosen to make a public statement about trans and non-binary inclusion. It has been produced with the support of our Rainbow staff network group, who have also welcomed the positive support from both our Ethnically Diverse and Lived Experience staff network groups. Our Rainbow staff network group is a diverse group of LGBTQ+ staff and allies.

We hope this statement will remind everyone that works in our organisation and uses our services that we are committed to building an inclusive and affirmative culture, that our staff are hugely valued for the role they do and the people they are, and that we are stronger and richer for the diversity that we all bring, as staff and service users.

We state that:

  • We proudly support the right of all people who use our services to receive positive healthcare, and to do so without fear of discrimination and hatred
  • We will provide high quality inclusive care every day to all and we are proud to do so
  • We are allies to those from marginalised groups who suffer the impact of prejudice and discrimination
  • We are proud to be a diverse and inclusive workforce and community for all


We are required to provide monthly reports about how many nurses and health care assistants we have working on wards and when we spend over £25,000.

This information is below. 

Safer staffing information

All NHS Trusts are required to publish monthly reports showing the number of nurses and health care assistants working on wards.

Providing this information is part of the Trust’s commitment to implement the National Quality Boards report ‘How to ensure the right people, with the right skills, are in the right place at the right time’.

This information is also available on national NHS website where it is published alongside other safety indicators that enable members of the public to see how hospitals are performing on this issue.

Our safer staffing reports show ward by ward data on actual versus planned numbers of staff by registered nurse and care staff, and day duty and night duty.

Monthly Returns

Expenditure over £25,000

We are committed to openness and transparency around how we spend public funds.

The Government requires us to publish any expenditure over £25,000 on our website. This includes any invoices, grants, expenses or other transactions over £25,000.

Any payments protected under the Data Protection Act, such as salary payments to staff, are excluded from publication.

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