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

In December 2011 we provided a statement in response to the Bribery Act 2010.

To view the statement click here.

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 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 NICE guidance.

Medicines that do not have sufficient justification of cost effectiveness 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.

You can read our formulary statement by clicking here

Modern slavery statement

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 by clicking here.

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

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.

The actions we have already taken include:

  • Adhering to the National NHS Employment Checks / Standards (This includes employees UK address, right to work in the UK and suitable references).
  • Building systems to encourage the reporting of concerns and the protection of whistle blowers, including our Freedom To Speak Up Guardian that all staff can access to raise concerns via.
  • A review of all safeguarding referrals via our incident reporting system and data is shared at our Safeguarding Governance and Patient Safety Committee
  • Each Directorate has a designated lead officer for Safeguarding Adults who is supported by the Trust Lead for Safeguarding.
  • Ensures full implementation of the Safeguarding Adults Policy and the South Yorkshire Safeguarding Adults Procedures through a multi directorate Safeguarding Adult Steering Group led by the Deputy Chief Nurse.
  • Participating in the multi-agency Sheffield Adult Safeguarding Board and its associated sub boards to support the South Yorkshire Safeguarding Adult Procedures.
  • Including links to the referral process for adults at risk in our Safeguarding Adults Policy.
  • Building long standing relationships with our suppliers and made clear our expectations of business behaviour. Where national or international supply chains are used, we expect these suppliers to have suitable anti-slavery and human trafficking policies and procedures and where there is a risk of Slavery and Human Trafficking taking place, steps will be taken to assess and manage that risk.
  • Developed a level of communication with the next link in the supply chain and their understanding of, and compliance with, our expectations in relation to the NHS terms and conditions. These conditions relate to issues such as bribery, slavery and other ethical considerations.
  • We’re working in partnership with multi-agency partners leading on this agenda in South Yorkshire and ensure that we are represented on these committees.
  • Ensuring that Modern Slavery and Human Trafficking training is available to staff and incorporated in safeguarding 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 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.

You can view our self-certification for 2021-22 by clicking here.

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 working in partnership.

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.

You can read our formal response to the Francis Report made in 2013 by clicking here

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 care is provided in 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 50% of each assessment team must be service users. The other 50% are 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 indicating how we intended 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 by clicking here.


Sheffield Health and Social Care NHS Foundation Trust, like all public sector organisations, have a legal duty to protect children and vulnerable adults from harm wherever possible.

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

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.

All our staff 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 Assurance Self Assessment for 2021-22 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. We encourage service users, visitors and staff to report all such incidents as soon as they occur. We would, of course, prefer that incidents against our staff did not occur. However, we have a ‘zero tolerance’ attitude towards such behaviours and 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.

We are proud to support the key principles 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 are striving to demonstrate our organisation's support for the armed forces community. 

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

You can find out more about the Armed Forces Covenant on the website and view our signed statement by clicking here

Trade Union Facility Time

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

The regulations require the Trust to collate and publish a range of data on the amount and cost of ‘facility time’ for the organisation.

‘Facility time’ is the provision of paid or unpaid time off from an employee’s normal role to undertake trade union duties and activities as a trade union representative.

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

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

The data has now been collated for the reporting year 01 April 2020 to 31 March 2021 and 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


We are required to provide monthly reports on our staffing levels and financial spend over £25,000.

In the section below you can take a look at our returns since we began capturing this data. 

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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