Title of the Paper: · Web viewThis paper presents the outcome of the establishment review of adult...

Title of the Paper:

Title of the paper:

Safe staffing – nursing and midwifery, bi-annual skills mix and month 3, 4 and 5 report

Agenda item:

334/21

Lead Executive:

Tracy Carter, Chief Nurse & Director for Infection Prevention and Control

Author:

Toni Nettleton, Lead Nurse Workforce

Trust objective:

Tick as appropriate:

|X|Achieving continuous improvement in the quality of patient care that we provide and the delivery of service performance across all areas;

|_|Setting out our future clinical strategy through clinical leadership in partnership and with whole system working;

|_|Creating a clear and credible long term financial strategy.

Purpose:

To provide information and next steps following the establishment review of adult inpatient wards and an update on progress regarding the arrangements for managing safe nursing and midwifery staffing levels.

Previously discussed and date for further review:

Committee

Date

Trust Leadership Executive Committee

25 September 2014

PSQR

2 October 2014

Benefits to patients and patient safety implications

To assure we have sufficient qualified, skilled and experienced staff to meet patient care needs within our adult inpatient wards to give good quality care.

Risk implications for the Trust

Patient safety and clinical care are likely to suffer as a consequence of not having the right staff with the right skills in the right place at the right time.

Mitigating actions (controls)

Utilisation of bank and agency to maintain safe staffing levels. Implementation of a real time database and trust-wide shared access for senior nurses to identify risks and manage nursing and midwifery levels on a day to day basis.

Links to Board Assurance Framework, CQC outcomes, statutory requirements

The Care Quality Commission (CQC), under regulation10(3) of the Health and Social Care Act 2008 (Regulated activities) Regulation 2010

Legal implications

Financial implications

Recommendations

To approve the proposed changes.

To note month 3, 4 and 5 reports.

Trust Board Meeting

9 October 2014

Agenda Item: 334/21

Trust Board – 09 October 2014

Safe staffing – nursing and midwifery, bi-annual skills mix

Presented by: Tracey Carter Chief Nurse and DIPC

1. Purpose

1.1 This paper presents the outcome of the establishment review of adult in-patient wards to determine if the nurse staffing levels within in-patient adult wards have sufficient qualified, skilled and experienced staff to meet patient care needs.

1.2 To provide an update regarding the arrangements for managing safe nursing and midwifery staffing levels within the inpatient wards.

2. Background

2.1 Since the publication of the report from the Mid-Staffordshire NHS foundation Trust public inquiry (2003), the review of increased Mortality rates in 14 trusts by Bruce Keogh (2013) and Don Berwick’s review into patient safety (2013), risks to patients were highlighted where organisations had not taken seriously when it had been identified that the right people with the right skills at the right place and time were not in place.

2.2 Collectively the National Quality Board, Chief Nursing Officer England along with experts have now set out clear expectations of NHS providers and commissioners through the paper ‘How to ensure the right people with the right skills, are in the right place at the right time’ (2013).

2.3 The Care Quality Commission (CQC), under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, ask that Trusts are assured that there are sufficient numbers and mix of staff on duty to provide the best and safest care to the people using the hospital. See appendix 1- 3 for Nursing and Midwifery safe staffing papers for June July and August.

2.4 A previous review of adult inpatient areas was undertaken across West Hertfordshire Hospital Trust (WHHT) in May 2013. The review utilised the following tools and benchmarks:

· Patient Dependency tool that benchmarks best practice wards in the UK covering 28 clinical specialities by Keith Hurst - evidence based tool.

· Professional Judgement and scrutiny to interpret results that takes into account local context and patient needs including ward layout and design.

· Best practice recommendations were utilised in areas where the patient dependency tool was not specific e.g stroke units, high dependency units.

· All results were triangulated and reflected the totality of Registered Nurses and support staff.

· Results were also benchmarked against the Royal College of Nursing (RCN) minimum recommendation of 1:7 nurse to patient ratio and trained to untrained skill mix. See appendix 4 for explanation of nurse to bed and staff to bed ratios and current ratios within our adult in patient wards.

2.5 As recommended in the report from the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) each ward has 37.5hrs of Band 7 acting in a supervisory capacity to enable nurse leadership except in emergencies, as part of the nursing provision on the ward.

2.6 Between June 23rd and July 11th 2014 the Chief Nurse led a further review of adult ward based nursing establishments supported by the Lead Nurse for workforce in partnership with the divisional heads of nursing. National Institute for Health and Care Excellence (NICE 2014) recommend that several models are used when undertaking establishment reviews to provide balanced assurance and the results are triangulated. This review has also included the Safer Nursing Care Tool (SNCT) which was not used in the previous establishment review. The NHS institute of innovation and improvement deemed the SNCT not fit for purpose in 2013 but it has now been revised and re-launched and deemed appropriate for use as an evidence based tool. A summary of outputs can be found in appendix 5 and strengths and limitations of tools utilised in appendix 6.

2.7 Following the establishment review NICE published its guidance for safe staffing in adult inpatient wards in acute hospitals and made a number of recommendations in relation to organisational strategy, principles for determining nurse staffing requirements, setting the ward nursing staff establishments, monitoring and evaluating ward nursing staff establishments. NICE also comment there is evidence of increased risk of harm when a registered nurse is caring for more than 8 patients during a day shift; this guidance was also considered within the review. NICE also recommend each ward should determine the requirements for nursing staff to ensure safe patient care and there is no single nursing staff to patient ratio that can be applied across the whole range of wards.

3. Analysis/Discussion

3.1 The data sheets were reviewed by Lead Nurse for workforce with the Heads of Nursing. The multipliers for SNCT (Appendix 7) and dependency benchmarks (Appendix 8) were adjusted to reflect the 21.6% uplift applied at WHHT. An assumption of 100% occupancy was incorporated into the analysis with any blanks scoring zero as staff did not capture patients pending arrival to the ward following discharges. Exclusions were also made for escalation areas (i.e Acute Stroke Unit gym) and supervisory band 7 roles.

3.2 All band 7s and Matrons were consulted and proactively contributed to their clinical areas under review as indicated in the NICE principals for determining and setting ward establishments. The results were scrutinised and challenged by the heads of nursing and the Chief Nurse.

Surgery and Gynaecology wards

3.3 The triangulated variance across Surgical and Gynaecology wards was -0.77wte. This indicated that the Nursing establishment across surgery and Gynaecology is currently safe. All wards that have a higher nurse to bed ratio at night have elective capacity and were professionally judged as appropriate for the case mix.

3.4 It is recommended that the division review opportunities to move staff across wards in response to the review outcomes.

Care of Older people wards and Dual Frailty Unit

3.5 The current SNCT is being revised for use within older people’s wards and we are awaiting the outcome. The triangulated variances across the two care of older peoples wards Sarratt and Croxley was 5.53wte.

3.6 These areas showed a significant variance in results in one of the models. The dependency model is based on activities of daily living data that may not be reflective of the real dependency of the patients in these wards. This is recognised as a weakness of the tool. Further analysis will be undertaken in October 2014 to reassess the acuity and dependency of our older people’s wards and consider options to merge the nursing workforce across both wards to maximise efficiencies. Both wards currently meet all the RCN safe staffing minimum recommendations to deliver care to older people of 1:7 nurse to bed ratio, 50/50 skill mix and staff to bed ratio of 3.2 – 3.8.

3.7 There is currently no guidance or benchmarks for staffing ratios or skill mix for the new Dual Frailty Unit. The unit cares for older people with complex needs and has been professionally judged to be suitably staffed to safely care for patients with complex care needs.

General Medical wards

3.8 The triangulated variance for Winyard ward was 3.5wte and Red Suite 2.68wte. These are both small 18 bedded wards. The current registered nurse to bed ratio on days in both areas is 1:6 the staff to bed ratio is 1:4. On nights the nurse to bed ratio is 1:6 on both wards, but the staff to bed ratio is 1:5 on Red Suite and 1:4 on Winyard ward. Professional judgement has taken into account the size, layout and location of these units within the main hospital and has deemed current levels of staffing appropriate to maintain patient and staff safety day and night within these areas. The current nurse and staff to bed ratios are in line with other acute medical wards within the Trust.

Specialist medical wards

3.9 The triangulated variance across the medical specialty wards was 1.60wte, this indicated the Nursing establishment is currently safe. Heronsgate ward in 2 models indicates they require an increase to their current establishment however a regular review of this area will continue to monitor fluctuations or changes to acuity and dependency over time before any adjustment is made.

Acute Assessment Unit (AAU) Level 1

3.10 The AAU has a total of 45 beds, 18 of which are monitored and 9 are unsighted cubicles away from the main clinical ward areas. The triangulated variance for AAU L1 is 6.61wte. Whilst the model triangulation indicated that there is a variance of between 1.87 and 2.49wte within each ward, professional judgement has taken into account layout and design of the areas and has deemed current levels of staffing appropriate to maintain patient safety day and night within the current bed configuration.

3.11 As part of the unscheduled care work stream AAU level 1 will be changing its focus to improve patient flow, pathways and efficiency. Within this project discussions on the re-configuration of beds and the potential merger of clinical areas to maximise flexibility and efficiencies within the current nursing workforce are taking place.

Acute Assessment Unit (AAU) Level 3 and Cardiac care unit (CCU)

3.12 The total triangulated variance for the three clinical areas within L3 of the AAU; Green and Purple, Blue and Yellow was 17.87wte.

3.13 All areas in AAU level 3 were professionally judged to currently have the appropriate level of staff in place to deliver safe care to patients due to the current bed configuration including a 6 bedded isolation area, 12 cardiac monitored beds and 6 unsighted cubicles that are all away from the main bays of each ward. The CCU has 11 monitored beds and a triangulated variance of 2.24wte.

3.14 A reconfiguration of AAU Level 3 has been proposed that includes the relocation of the CCU to AAU Level 3 with 24 monitored beds to reflect changes in patient pathways, resulting in an improved patient experience. This change will improve efficiency across the areas allowing a reduction of 5.67wte posts with a predicted saving of £267,000 over 12 months (See appendix 9)

Aldenham Ward

3.12 Aldenham ward is comprised of 21 respiratory beds and a 6 bedded high dependency unit (HDU). The triangulated variance was 4.22wte.The HDU is funded to provide level 2 care for a designated cohort of patients, however the 3 week audit indicated a reduced number of level 2 admissions than expected. As a result the recommended establishment was less than the funded establishment.

3.13 Based on current acuity and dependency evidence it is proposed to reduce the trained nursing planned hours by 11.5 a day (2.61wte trained nurses). It should be noted that the acuity and dependency may not be reflective of the autumn, winter and spring seasons within this respiratory ward and therefore the ward will be closely monitored on a daily basis over the coming months.

3.14 If further reviews indicate that demand remains lower than anticipated, the Trust should consider options for further reconfiguration of the bed base.

4. SUMMARY

4.1 The review utilised three tools to agree safe staffing levels. In light of the strengths and weaknesses of the tools, professional judgement and scrutiny was applied to provide a balanced assurance. The paper ‘How to ensure the right people with the right skills are in the right place at the right time’ (2013) is clear that using tools are only one approach to making decisions on staffing and that professional judgement and scrutiny are critical when evaluating tool results to ensure decisions are based on patient care needs and knowledge of the local context.

The overall triangulated variance from the three tools was 49.79wte. Based on acuity and dependency outputs, proposed bed re-configurations and professional judgement and scrutiny of the results a further 8.28wte were reduced from the initial overall variance.

4.2 The summary of findings indicates that overall our clinical adult inpatient wards have sufficient nursing staff on a shift by shift, day by day basis to safely care for patients.

4.3 The nurse to patient ratio in all clinical areas is currently a minimum of 1:7 on days and meets the minimum RCN recommendations.

4.4 At night the nurse to patient ratio is a minimum of 1:8 with the exception of 3 clinical wards within surgery whose nurse to patient range was between 1:9 and 1:10, theses areas have an elective case mix and were professionally judged as appropriate.

4.5 The RCN recommends a 65/35 - 70/30 trained to untrained skill mix and 50/50 - 65/35 in older peoples wards. Of the twenty four clinical areas reviewed, eight fell below this benchmark. This parameter however should not be looked at in isolation to assess safe staffing but should be seen in conjunction with other parameters such as the nurse and staff to bed ratios.

5. Next steps

5.1 As recommended a review of ward establishments should be undertaken on a biannual basis as a minimum and presented to the Trust Board. Acuity and dependency reviews should be carried out a minimum of 3 times a year to capture seasonal variances.

5.2 To discuss the development of a daily acuity and dependency measurement tool across our inpatient ward areas.

5.3 A profile of the experience and capability of the substantive workforce should be undertaken to inform future reviews including vacancies, agency usage and staff turnover.

5.4 Further opportunities to merge or re-configure should be considered for small wards/units to optimise efficiency and flexibility of the nursing workforce.

5.5 Senior nurse coverage at Band 7 and 6 should be profiled and benchmarked to achieve equity across all in patient clinical areas.

5.6 To carry out a detailed review of ward budgets to determine and agree the distribution and recruitment of uplift required to support sickness, annual leave and study leave. Some clinical areas are noted to have recruited to the full 21.6% budget uplift which impacts on their ability to flexibly utilise the nursing workforce.

5.7 A full review and profile of unregistered clinical roles should be undertaken across all clinical areas to inform and support the development of an unregistered workforce strategy.

5.8 To continue the development of an integrated performance report that will be owned by the ward managers and senior nursing divisional teams. The report will include both quality and workforce metrics for example monthly data on falls, pressure ulcers, test your care and I want great care, sickness/absence, and vacancies. This will assist in measuring the safety and patient experience within our wards and provide further ward to board assurance.

5.9 Review specials and escort use and investigate options for a pool to be developed with specialist skills and reduce temporary usage.

5.10 Complete SNCT and dependency tools again in October 2014.

5.11 Review and present papers on Maternity and children’s skill mix and establishments by December 2014.

6. Recommendations

6.1 The committee is asked to approve the proposed changes.

Tracey Carter Chief Nurse

15th September 2014

Appendix 1

Nursing and Midwifery Safe Staffing - month 3

1. Purpose

1.1 This paper provides an update on the progress regarding the arrangements within the Trust for managing safe nursing and midwifery staffing levels within the inpatient ward.

2. Background

2.1 It is now a national requirement for all hospitals to publish information about staffing levels on wards, including the percentage of shifts meeting their agreed staffing levels. This initiative is part of the NHS response to the Francis report which called for greater openness and transparency in the health service.

2.2 A Nursing and Midwifery safe staffing paper was presented to the Trust Board in July 2014 in response to the National Quality Board guidance in ensuring compliance and commitment to the 10 expectations and recommendations, CQC compassion in practice and recent National reports Mid Staffordshire Public Enquiry, Keogh and Cavendish reviews and the Berwick safety report.


3.1 The Trust submitted all unify data to NHS England as required by the 10th July 2014 this will be available to view on NHS Choices website on or around the 24th July allowing patients and the public to see how hospitals are performing.

See appendix 1 for June 2014 unify data by site and ward.

Overall the Trust saw a decrease in the percentage of filled hours against planned in June. Over 33 wards/areas, this equated to 1,117 hrs unfilled hours for trained staff and 254 hours for health care assistants on day shifts. On night shifts 414 hours were unfilled for trained nurses/midwives against the planned hours required on duty, for healthcare assistant 58 hours were on duty above planned hours.

All shifts day and night are professionally judged by the nurse in charge of the clinical area for safety by RAG rating. Mitigations to maintain safe staffing were put in place where risks were highlighted and concerns escalated in accordance with the Nursing and Midwifery safe staffing escalation policy.

It is important to note that actual staffing levels submitted via the unify return comprise all staff on duty including staff that were unplanned for trained and healthcare assistants e.g 1:1 specials, escorts. This in turn would distort the actual levels of staff required on duty to deliver safe patient care as these are essential staff and would be above the required agreed planned hours.

The data therefore should not be looked at in isolation but be considered in line with the shift RAG ratings exception report. See tables 1–3 below for the comparison data and trends overall in the trust and then by hospital.

Table 1 – West Hertfordshire Hospitals overall percentage of filled against unplanned hours

Table 2 – St Albans City Hospital percentage of hours filled against unplanned

Table 3 – Watford General Hospital percentage of hours filled against planned

Monthly comparison data and trends of the percentage of filled hours against planned by division is shown in tables 4–6 below.

Table 4 - Medicine percentage of filled hours against planned

Table 5 – Surgery percentage of hours filled hours against planned

Table 6 - Womens and Childrens percentage of filled hours against planned

Some clinical areas are noted to have an increase in hours above planned for health care assistants due to fluctuations in the acuity or dependency of patients on some shifts e.g 1:1 specials, additional hours were required to maintain patient safety and would be above the planned requirements of the daily staffing agreed.

3.2 Across all ward and departments there were 2,322 day and night shifts 2,215 shifts were rated green, 106 rated amber and 0 shifts were rated red in June 2014. See appendix 2 for monthly detail by ward/department that incorporates areas not included in the unify data reporting.

The trust overall saw an increase in amber RAG rates during the month of June. Shifts rated amber rose by 2.6% from the previous month. See table 1 below.

Table 1 - West Hertfordshire Trust overall percentage shift RAG rating.

All divisions reported an rise in amber rated shifts, 1% in medicine, 0.4% in surgery and 8% in the division of women’s and children from the previous month, see tables 2-4 below for comparison data.

Table 2 - Medicine monthly percentage shift RAG rating

Table 3 - Surgery monthly percentage shift RAG rating

Table 4 – Women and children’s monthly percentage shift RAG rating

All areas who rated amber on a day or night shift took action to mitigate any risks to maintain patient safety. Appendix 3 provides the detail for the safe staffing exception report for June 2014, by division and ward, with mitigations to maintain safe staffing on the amber rated days.

3.3 The establishment reviews for in-patient clinical areas and will be presented to

the trust board in September 2014.

4. Risks

4.1 Managing unexpected fluctuations in patient acuity and dependency both during shifts and out of hours that require a higher level of staff than the agreed daily requirement.

4.2 Surge areas that are opened in response to fluctuations in patient activity are at risk of not having the appropriate safe staffing due to dependency on temporary staff.

4.3 Data is currently sourced from both electronic and manual data entry to enable ratification of robust data collection. User error and administrative failure pose a risk to accurate data gathering and assurance.

5. Recommendations

5.1 The committee is asked to:

· Note the information and assurance

· Note the ongoing work and actions

Jackie Ardley

Chief Nurse

16th July 2014

Appendix A

West Hertfordshire Hospitals Unify Fill rate indicator return Staffing: Nursing, midwifery and care staff June 2014

Day

Night

Registered midwives/nurses

Care Staff


Care Staff

Day

Night

Site Code

Site Name

Total monthly planned staff hours

Total monthly actual staff hours







Average fill rate - registered nurses/midwives (%)

Average fill rate - care staff (%)



RWG03

St Albans City Hospital

1927

1997.5

852.5

867

1104

1115.5

345

310.5

103.7%

101.7%

101.0%

90.0%

RWG02

Watford General Hospital

51432

50245

25268.5

25000

44114

43688.5

17905.5

17997.5

97.7%

98.9%

99.0%

100.5%

West Hertfordshire Hospitals Unify Fill rate indicator return by ward

Day

Night

Day

Night

Hospital Site Details

Ward name

Main 2 Specialties on each ward


Care Staff


Care Staff





Hospital Site name

Specialty 1

Specialty 2









RWG02

Watford General Hospital - RWG02

AAU Blue Level 1

300 - GENERAL MEDICINE

1155

1147.5

690

667

1035

989

690

713

99.4%

96.7%

95.6%

103.3%

RWG02


AAU Yellow Level 1


1170

1181.5

690

793.5

1035

1035

690

759

101.0%

115.0%

100.0%

110.0%

RWG02


AAU Green Level 1


1177.5

1193

690

690

1035

1035

690

690

101.3%

100.0%

100.0%

100.0%

RWG02


AAU Red Suite


1192.5

1177.5

690

678.5

1035

1012

345

345

98.7%

98.3%

97.8%

100.0%

RWG02


AAU Triage Level 1


1968

1795.5

859

962.5

1035

1012

690

713

91.2%

112.0%

97.8%

103.3%

RWG02


AAU Blue Level 3


1440

1302

1035

1023.5

1380

1345.5

690

713

90.4%

98.9%

97.5%

103.3%

RWG02


AAU Yellow Level 3


1177.5

1128

690

632.5

1035

1000.5

345

356.5

95.8%

91.7%

96.7%

103.3%

RWG02


AAU Green & Purple Level 3


1764

1737

1380

1276.5

1380

1357

690

667

98.5%

92.5%

98.3%

96.7%

RWG02


Bluebell

430 - GERIATRIC MEDICINE

1537.5

1526

1380

1334

1380

1357

1380

1403

99.3%

96.7%

98.3%

101.7%

RWG02


Winyard


1192.5

1158.5

690

686

1035

954.5

690

667

97.1%

99.4%

92.2%

96.7%

RWG02


Sarratt


1882.5

1994

1380

1744

1725

1725

1035

1322.5

105.9%

126.4%

100.0%

127.8%

RWG02


Croxley


1537.5

1476

1035

1184.5

1380

1380

1035

851

96.0%

114.4%

100.0%

82.2%

RWG02


Coronary Care Unit (CCU)

320 - CARDIOLOGY

1605

1515

241.5

230

1380

1380

0

0

94.4%

95.2%

100.0%

#DIV/0!

RWG02


Cassio


1192.5

1189

690

989

1035

1035

345

655.5

99.7%

143.3%

100.0%

190.0%

RWG02


Gade

370 - MEDICAL ONCOLOGY

1192.5

1139.5

690

667

1035

1035

0

126.5

95.6%

96.7%

100.0%

#DIV/0!

RWG02


Heronsgate


1192.5

1216

782

705

1035

1035

345

345

102.0%

90.2%

100.0%

100.0%

RWG02


Aldenham


2227.5

2151

1035

1012

2070

2047

345

391

96.6%

97.8%

98.9%

113.3%

RWG02


Acute Stroke Unit Watford


2572.5

2515

1260

1337

2415

2415

1035

1104

97.8%

106.1%

100.0%

106.7%

RWG03

St Albans City Hospital - RWG03

De La Mare/Beckett

100 - GENERAL SURGERY

1927

1997.5

852.5

867

1104

1115.5

345

310.5

103.7%

101.7%

101.0%

90.0%

RWG02


Letchmore


1192.5

1154

690

701.5

1035

1023.5

345

345

96.8%

101.7%

98.9%

100.0%

RWG02


Ridge


1537.5

1542

1035

885.5

1035

1012

690

644

100.3%

85.6%

97.8%

93.3%

RWG02


Flaunden


1537.5

1537.5

1035

1012

1380

1345.5

345

391

100.0%

97.8%

97.5%

113.3%

RWG02


Cleves


1192.5

1153.5

1035

959.5

1035

989

345

437

96.7%

92.7%

95.6%

126.7%

RWG02


Langley


1089

1058.5

448.5

570

690

667

345

333.5

97.2%

127.1%

96.7%

96.7%

RWG02


Combined ITU

192 - CRITICAL CARE MEDICINE

5163.5

5163.5

333.5

345

5129

5129

333.5

310.5

100.0%

103.4%

100.0%

93.1%

RWG02


Starfish

321 - PAEDIATRIC CARDIOLOGY

1276.5

1290.5

345

295

1023.5

977.5

345

264.5

101.1%

85.5%

95.5%

76.7%

RWG02


SCBU

321 - PAEDIATRIC CARDIOLOGY

2116

2395.5

989

736

2081.5

2254

1012

828

113.2%

74.4%

108.3%

81.8%

RWG02


Elizabeth Ward

502 - GYNAECOLOGY

1537.5

1552.5

690

674

1035

1046.5

690

632.5

101.0%

97.7%

101.1%

91.7%

RWG02


Delivery Suite

501 - OBSTETRICS

3487.5

3236

690

580

3105

3024.5

690

552

92.8%

84.1%

97.4%

80.0%

RWG02


ABC

501 - OBSTETRICS

1260

1071

345

324

1035

1035

345

287.5

85.0%

93.9%

100.0%

83.3%

RWG02


Victoria

501 - OBSTETRICS

915

757

345

306.5

690

655.5

345

287.5

82.7%

88.8%

95.0%

83.3%

RWG02


Katherine

501 - OBSTETRICS

1605

1446.5

1035

699.5

1035

1035

690

563.5

90.1%

67.6%

100.0%

81.7%

RWG02


Knutsford

501 - OBSTETRICS

345

345

345

299

345

345

345

299

100.0%

86.7%

100.0%

86.7%

Appendix B

Number of day and night shifts (includes long days early and late shifts) planned against actual on duty.

Please note the actual staff on duty would include staff unplanned but essential to maintain patient safety e.g. 1:1 specials and staff rostered and working clinically on a period of supervision (orientation). These staff would be in addition to the planned staffing levels and distort the actual required staffing levels

Division

Area

No. of Day Shifts

No. of NightShifts

No. of Day Shifts

No. of NightShifts

Planned

Actual

Planned

Actual

Planned

Actual

Planned

Actual

Registered Nurses/Midwives

Healthcare Assistants

Medicine

AAU Blue Level 1

106

105

90

88

60

64

60

62

AAU Yellow Level 1

108

110

90

90

60

69

60

66

AAU Green Level 1

109

111

90

91

60

60

60

60

AAU Red Suite

111

115

90

90

60

59

30

30

AAU Triage

176

161

90

88

82

91

60

62

AAU Blue Level 3

127

127

120

119

90

89

60

62

AAU Yellow Level 3

109

113

90

86

60

56

30

31

AAU Green & Purple L3

160

178

120

120

120

118

60

58

Bluebell

141

151

120

119

120

129

120

123

Winyard

111

118

90

89

60

60

60

60

A&E

300

294

300

298

120

108

60

58

UCC Hemel

90

89

60

60

30

29

0

0

MIU SACH

60

60

0

0

0

0

0

0

Sarratt

171

190

150

150

150

156

90

115

Croxley

141

136

120

120

120

105

90

74

CCU

147

140

120

120

21

20

0

0

Cassio

111

110

90

90

60

86

30

57

Gade

111

107

90

90

60

58

0

11

Heronsgate

111

113

90

90

68

64

30

30

Aldenham

201

194

180

179

90

97

30

34

Acute Stroke Unit

231

231

210

211

90

126

90

96

Total

2932

2953

2400

2388

1581

1644

1020

1089

Division

Area

No. of Day Shifts

No. of NightShifts

No. of Day Shifts

No. of NightShifts

Planned

Actual

Planned

Actual

Planned

Actual

Planned

Actual



Surgery

Beckett

37

37

6

6

19

19

0

0

De La Mare

141

158

90

92

60

77

30

28

Letchmore

111

108

90

89

60

61

30

30

Flaunden

141

141

120

117

90

88

30

34

Ridge

141

151

90

88

90

77

60

56

Cleves

111

109

90

86

90

89

30

38

Langley

102

109

60

60

39

52

30

30

Combined ITU

449

449

446

446

29

30

29

27

Total

1233

1262

992

984

477

493

239

243

Women's & Childrens

Paediatrics

Starfish

111

116

89

85

30

29

30

23

CED

120

125

90

79

0

2

0

0

Safari Day Unit

42

70

0

0

16

16

0

0

Neonatal Unit

182

203

181

196

29

21

29

23

Transitional Care Unit

2

11

0

0

57

43

59

49

Gynaecology

Elizabeth

141

161

90

91

60

60

60

55

Maternity

Delivery Suite

321

335

270

263

60

63

60

48

Alexandra BC

120

118

90

90

30

34

30

25

Victoria

90

87

60

58

30

33

30

26

Katherine

150

158

90

90

90

70

60

49

Knutsford

30

30

30

30

30

26

30

26

Total

1309

1414

990

982

432

397

388

324

Appendix C

June 2014 Trust safe staffing exception report

Nursing & Midwifery Professional Judgement safe staffing RAG Rates

Green - Staffing numbers are as expected on the rota and ward is assessed as being safely staffed taking into consideration workload and patient acuity. Staffing numbers are not as expected but safe according to current workload.

Amber - Staffing numbers are not as expected and minor adjustments need to be made to bring staffing to a reasonable level given workload and acuity or staffing numbers are as expected but given workload and acuity additional staff are required.

Red - Staffing levels inadequate to cope with current patient needs.

Division

Area

Date

Shift

Professional Judgement Rag Rating

Comments, Mitigation - Actions Taken to Ensure Safe Staffing Levels

Medicine

AAU Blue Level 1

02/06/2014

Day

A

Supervisory covering Early.

08/06/2014

Day

A

Trained nurse sent home due to sickness @10.00 .Both band 6 to work with each Hca.

09/06/2014

Day

A

Supervisory to be counted on numbers.

AAU Blue Level 3

13/06/2014

Day

A

supervisory in numbers.

AAU Green L1

29/06/2014

Night

A

Had to move an RN to cath lab as open to 12 patient. Will be supported clinically by AAU L1 Blue, Yellow & Purple.

AAU Red Suite

30/06/2014

Day

A

1 RN off sick. Supervisory in numbers.

AAU Yellow Level 1

02/06/2014

Day

A

Supervisory working in numbers. RN shift not covered.

14/06/2014

Day

A

1 csw shift for specialing is not covered.

30/06/2014

Day

A

supervisory working in numbers.

Bluebell

27/06/2014

Day

A

CSW to special has cancelled for long day. Have a CSW for night shift to special. Supervisory in numbers to support.

A&E

07/06/2014

Day

A

Short by one ENP day shift- however 2 x ANPs on duty.

08/06/2014

Night

A

No ANP at night.

14/06/2014

Day

A

Day ENP worked 07:15-17:00. No senior A&E doctor cover at night. Senior manager on-call (JA) advised that department have a night ENP service. Senior nurse on shift ENPed.

17/06/2014

Day

A

2 senior nurses off sick , shifts out to NHSP, pulled 1 ENP as skill mix of concern. However the department is unsafe at present due to the skills required, remaining staff very junior.Nurse redeployed to support. Lead nurse supporting.

UCC Hemel

20/06/2014

Day

A

Anp sent from AE

.

Acute Stroke Unit

25/06/2014

Day

A

1 staff phoned in sick, 1 staff carers leave 3 patients in the stoke gym shifts out to NHSP. Not filled.

30/06/2014

Day

A

2 RN's overseas nurses - With no PIN number supporting on LD.

Croxley

14/06/2014

Day

A

1 RN short due to late sickness. Escalated to senior nurse. No spare staff available. NHSP shift times amended. Own staff contacted to see if they could cover. Allocated to ensure that risk to patient safety minimised. Worked closely with Sarratt ward to ensure 1:8 ratio was maintained.

28/06/2014

Day

A

1 bank staff nurse LD cancelled, escalated to senior sister on call. Requested wit ammended start time. Moved staff from Sarratt to maintain patient safety.2 bank nurses on the night are substantive staff.

Gade

04/06/2014

Day

A

HCA short on long day. Supervisory in the numbers to support.

05/06/2014

Day

A

LD short by one HCA. Senior Sister will cover AM shift

14/06/2014

Day

A

Sister on call informed no staff available

21/06/2014

Day

A

Moved staff to Heronsgate to cover there as they were short staffed.

27/06/2014

Day

A

we are 1 RN down. Shift was requested yesterday. Supervisory in numbers to support.

28/06/2014

Day

A

Bank nurse cancelled at the last minute. Bed manager informed no other staff available.

Surgery

Letchmore

28/06/2014

Night

A

One R.N short for the night shift. Multiple patient moves made off the ward over night, further increasing the work load. Bed manager and Bleep holder made aware at start of shift, additional staff requested however none available. Flaunden ward provided support with iv's

30/06/2014

Night

A

1 HCA not covered for LD, start time changed to 10.00hrs on NHSP system.Senior Nurse did not arrive for night shift. Only two juniors on ward, Poor skill mix, plus increased work load. Bed managers + Bleep holders made aware. Senior nurse from ward next door will help out.

Womens & Childrens

CED

02/06/2014

Day

A

Band 7 will cover as required.

05/06/2014

Night

A

Was covered but bank nurse off sick. Still trying to cover. Senior Sister is on call and can return if patient safety issue.

06/06/2014

Day

A

x1 night staff finishing at 07.00 so short for final hour. Starfish to support if required.

07/06/2014

Day

A

1 member of staff on a 1-6pm in the day. Senior sister on call will come in should any issue to patient safety arise. A&E aware of situation.

07/06/2014

Night

A

1 on night shift didn’t start till 9.30pm. Senior sister on call will come in should any issue to patient safety arise. A&E aware of situation.

10/06/2014

Day

A

Senior sister not supervisory

11/06/2014

Day

A

Will be covered by senior sister

14/06/2014

Night

A

Agency not filled. Staff on day worked 1400 -0230am to mitigate risk. A&E and Starfish aware, will support.

15/06/2014

Night

A

out to agency -not filled. Staff on MLD worked 1400 -0230am. A&E and Starfish aware, will support if required.

19/06/2014

Day

A

Will move nurses around ther service as required according to activity. Senior sister already clinical.

30/06/2014

Night

A

Night short after 04.30. A&E and Starfish aware, will support if required

Neonatal Unit

01/06/2014

Day

A

total 14 babies on SCBU. Unit was safe as there were no admissions

Starfish

12/06/2014

Day

A

2 students, 1 3rd year plus help from Safari.

15/06/2014

Night

A

shift out to agency who were unable to cover. Dependency of patients high. CED staff available and are able to assist if needed. Senior nurse on call and are aware of the situation, available for advice by telephone where needed.

16/06/2014

Day

A

Supervisory band 7 avaliable to assist on ward. Patient dependency high. Shift out to agency

17/06/2014

Day

A

CSW shift out to agency. Band 7 avaliable to assist if needed

25/06/2014

Night

A

One trained member off staff short. Band 7 avaliable to assist if neededNight= Increased activity+admissions overnight , agency nurse did not have skills suitable for the ward. CED aware and are able to assist if needed. Senior nurse on call available.

Elizabeth

07/06/2014

Day

A

Bank worker RGN cancelled shift long day. Currently have one pt who needs ITU bed but none available (patient to be monitored hourly). Also have a patient booked for medical management today. Bed manager informed. No cover found. Staff split into 2 bays each and nurse in charge managed the medical management and the ITU patient.

07/06/2014

Night

A

Currently have one pt who needs ITU bed but none available (patient to be monitored hourly). Also have a patient booked for medical management today. Bed manager informed. No cover found. Staff split into 2 bays each and nurse in charge managed the medical management and the ITU patient.

13/06/2014

Day

A

Matron informed of staff shortage & would raise this at the meeting. No Supervisory to pull, no extra staff available to support. Request to Maternity for HCA for this aftenoon - evening to support and shift times changed on NHSP to start at 1300hrs. There are no Electives today but there are 4 Gynae patients in AAU and 1 in ITU requiring repatriation. The ward is safe but busy.

14/06/2014

Night

A

Hca sick for night duty, bed managers informed & would send someone if they can

15/06/2014

Night

A

Short of 1 hca tonight, oncall senior nurse informed, shift out to bank. Not covered but Band 5's split ward into managable areas making the ward busy but safe.

21/06/2014

Night

A

1 Additional RGN booked for day shift for medical management. Short of 1 HCA at night. Shift out to NHSP & A5 completed and sent to Senior Nurse on call. Not covered but staff on duty shared responsibility through having 2 bays each and doing all their own vital signs. Busy but safe.

24/06/2014

Day

A

Band 7 in numbers and not supervisory. Late cannot cover from own staff and NHSP not covered.

26/06/2014

Day

A

x1 RN supernumery can't work unsupervised. X6 elective patients to get in and no beds empty at present. Only 2 confirmed discharges. Band 6 co-ordinated the shift and split the rest of the staff into 2 bays each with the assistance of the hca's. Band 7 on A/L

Delivery Suite

01/06/2014

Night

A

no HCA for triage or D/S, will deploy from other areas

02/06/2014

Day

A

Support shifts vacant requiring sharing between clinical areas.

02/06/2014

Night

A


05/06/2014

Day

A

HCA deployed from another clinical area for day shift , 1 shift remains unfilled, day and night. Staff moved between clinical areas affected to manager activity depending on clinical demands.

05/06/2014

Night

A

1 shift remains unfilled night. Staff moved between clinical areas affected to manager activity depending on clinical demands.

06/06/2014

Night

A

short of HCA in night will have to redeploy from other areas

07/06/2014

Day

A

1 midwife DNA, agency contact, 1 redeployed to another area due to activity, therefore staff for maternity triage not available, triage re-deployed to delivery suite whilst trying to arrange cover.

09/06/2014

Day

A

1 support staff shift unfilled, will require sharing between clinical areas or redeployment if shift remains unfilled on NHSP.

11/06/2014

Night

A

No HCA on D/Suite - shift out to NHSP. Agency midwife DNA on night shift. Shift put out again but not filled. Will have to move midwife from another area if needed.

12/06/2014

Day

A

1 midwife down on DS, already out to NHSP. Redeployed staff within division to cover when needed.

17/06/2014

Day

A


19/06/2014

Day

A

One Midwife moved from ABC to cover shortfall.

28/06/2014

Day

A

1 shift unfilled, support staff utilised, and local redeployment.

30/06/2014

Day

A

1 midwife cancelled 07.40 redeployment not possible due to current activity triage centralised on delivery suite ths may need to continue to mitigate for vacant shift. 1 midwife DNA shift unfilled.

ABC

01/06/2014

Day

A

no HCA but will redeploy from another area

02/06/2014

Night

A


03/06/2014

Day

A

1 midwife early shift unfilled, supernumerary utilised to support

04/06/2014

Night

A

No support staff on nights. Will get HCA to help from another area if needed

05/06/2014

Day

A

Day and night. No HCA. Shift put out to NHSP. Midwife shift unfilled on NHSP. Support from other clinical area

05/06/2014

Night

A

Day and night. No HCA. Shift put out to NHSP. Midwife shift unfilled on NHSP. Support from other clinical area

07/06/2014

Day

A

1 midwife deployed from delivery suite due to activity, no support staff available.

11/06/2014

Day

A

No Midwife on late. Shift put out to NHSP. Support from other clinical area

13/06/2014

Night

A

No HCA on night. Shift put out to NHSP. Will have to get help from another area if not filled.

15/06/2014

Day

A

One midwive down on late shift. Shift out to bank but not filled. HCA from Victoria Ward to help.

15/06/2014

Night

A

No HCA on night shift. Shift out to bank but not filled. HCA from Victoria Ward to help.

28/06/2014

Day

A

1 shift unfilled activity managed within current staffing capacity.

Victoria

01/06/2014

Day

A

no HCA support will redeploy from another area if required

04/06/2014

Night

A

No support staff on nights. Will get HCA to help from another area if needed

10/06/2014

Night

A

Will have to get HCA from ABC to cover Victoria Ward as well as ABC

16/06/2014

Day

A

HCA had to be redeployed to another area. HCA from ABC to help.

16/06/2014

Night

A

HCA had to be redeployed to another area. HCA from ABC to help.

Katherine

02/06/2014

Night

A

No nursery nurse available, midwife will be required to under take these duties

03/06/2014

Day

A

1 long day uncovered supernumary to support this morning, vacant shift on NHSP.

03/06/2014

Night

A

1 shift vacant. Vacant shift on NHSP. Support provided from other clinical areas.

04/06/2014

Day

A

Only 3 midwives on day shift, vacancy put out to NHSP. Midwife sent from DS to help with discharges. 4th midwife obtained for late shift to bring up to full complement of staff.

05/06/2014

Day

A

Day - No HCA or nursery nurse. No shift put out to NHSP

06/06/2014

Night

A

short of HCA on shift will redeploy from other areas, have SN staff to assist, no nursery nurse available on night shift.

07/06/2014

Day

A

No support staff for early shift, shift remained unfilled NHSP. Staff shared Katherine and Knutsford.

09/06/2014

Day

A

support shift unfilled will require sharing between Katherine and Knutsford

11/06/2014

Day

A

Only 1 HCA . Will have to get HCA from other area to help. No breast feeding support workers.

11/06/2014

Night

A

Only 1 HCA . Will have to get HCA from other area to help. No breast feeding support workers. Only HCA on night shift

12/06/2014

Day

A


13/06/2014

Night

A

No HCA on night. Shift put out to NHSP. Will have to get help from another area if not filled.

14/06/2014

Day

A

2 support staff shift unfilled, will require sharing between clinical areas or redeployment if shift remains unfilled on NHSP.

15/06/2014

Day

A

Midwife DNA'd for late shift. Shift on system but midwife not informed to work. Midwife came in and worked for 3 hours

15/06/2014

Night

A

Short of HCA's, will reploy within divsion to help support.

30/06/2014

Day

A

1 midwife not yet arrived for duty, shift remained unfilled due to failure of temporary staff arriving for duty. Ward manager utilised to cover .

Knutsford

03/06/2014

Night

A

No support staff, staff will be shared between Katherine and Knutsford

06/06/2014

Day

A

HCA shift vacant on day, shared responsibility Knutsford and Katherine.one of 3 shortages of HCA's will redeploy.

06/06/2014

Night

A

HCA shift vacant on night, shared responsibility Knutsford and Katherine.one of 3 shortages of HCA's will redeploy.

07/06/2014

Day

A

support staff shared between clinical area Katherine and Knutsford

10/06/2014

Night

A

No HCA but no patients at start of shift. HCA from Katherine ward to help if needed

12/06/2014

Day

A


Appendix 2

Nursing and Midwifery Safe Staffing - Month 4

1. Purpose

1.1 This paper provides an update on the progress regarding the arrangements within the Trust for managing safe nursing and midwifery staffing levels within the inpatient wards.

2. Background

2.1 It is a national requirement for all hospitals to publish information about staffing levels on wards, including the percentage of shifts meeting their agreed staffing levels. This paper will be reported monthly.

2.2 The Trust submitted all unify data to NHS England as required by the 11th August 2014 this will be available to view on NHS Choices website on or around the 24th August allowing patients and the public to see how hospitals are performing.

See Appendix 1 for July 2014 unify data by site and ward.


3.1 There has been discussion nationally that the breakdown of staffing data shown on NHS Choices does not distinguish between qualified and unqualified staff. This is seen as confusing for patients however as a Trust we do distinguish this in our reporting and the Board papers are then displayed for the public on our safe staffing page on the internet site.

3.2 On 1 July 2014 the National Institute for Health and Care Excellence (NICE 2014) published their guidance in relation to safer staffing and made a number of recommendations in relation to the following:

· Organisational strategy

· Principles for determining nurse staffing requirements

· Setting the ward nursing staff establishments

· Assessing if nursing staff available on the day meets the patients nursing needs

· Monitoring and evaluating ward nursing staff establishments

3.3 The recommendation from NICE that wards implement systems to report and monitor nursing ‘Red Flags’ has attracted much debate in the press. The guidance points to a number of patient factors that would denote a Red Flag event as well as quantifying a Red Flag in terms of staffing levels. The guidance recommends the following as constituting a Red Flag:

· Less than 2 registered nurses present on a ward during any shift.

· A shortfall of more than 8 hours or 25% (whichever is reached first) of registered nurse time available compared with the actual requirement for the shift. For example, if a shift requires 40 hours of registered nurse time, a red flag event would occur if less than 32 hours of registered nurse time is available for that shift. If a shift requires 15 hours of registered nurse time, a red flag event would occur if 11 hours or less of registered nurse time is available for that shift (which is the loss of more than 25% of the required registered nurse time.

· Organisations to agree their own red flag events locally

In response to the NICE Guidance, a gap analysis will be undertaken in September with senior nurses to benchmarking current practice against the recommendations. In particular we will be working with national leads to better understand the application of the Red Flag system and reconciling the percentages outlined above with the fill rates included in West Hertfordshire Hospitals Trust Safer Staffing submission. The outcome and action plan will be presented at the Trust Board in November 2014.

3.4 In July the Trust reported 1,094 unfilled hours for trained nurses and midwives and 841 hours above planned for health care assistants on day shifts. On night shifts 552 hours were unfilled for trained nurses/midwives against the planned hours required on duty, for healthcare assistant 839.5 hours were on duty above planned hours. Some clinical areas are noted to have an increase in hours above planned for health care assistants due to fluctuations in the acuity or dependency of patients on some shifts e.g 1:1 specials and escorts.

3.5 All shifts day and night are professionally judged for clinical safety and escalated in accordance with the Nursing and Midwifery safe staffing escalation policy.

3.6 It is important to note that actual staffing levels submitted via the unify return comprise all staff on duty including staff that were unplanned for trained and healthcare assistants e.g 1:1 specials, escorts. This in turn would distort the actual levels of staff required on duty to deliver safe patient care as these are essential staff and would be above the agreed planned hours. The data therefore should not be looked at in isolation but be considered in line with the shift red amber green (RAG) ratings exception report. See tables 1–3 below for the comparison data and trends overall in the trust and then by hospital.

Table 1 – West Hertfordshire Hospitals overall percentage of filled against unplanned hours

Table 2 – St Albans City Hospital percentage of hours filled against unplanned

Table 3 – Watford General Hospital percentage of hours filled against planned





3.7 Across all ward and departments there were 2,370 day and night shifts 2,307 shifts were rated green, 63 rated amber and 0 shifts were rated red in July 2014. See appendix 2 for monthly detail by ward/department which also includes areas not in the unify data reporting.

The trust overall saw a reduction in amber ratings during the month of July Shifts rated amber decreased by 1.87% from the previous month. See table 1 below for monthly trends.


The division of Women’s and children’s reported a decrease in amber rated shifts by 10.2% however the divisions of Medicine and Surgery reported an increase of amber rated shifts in July, 0.3% in medicine and 2.4% in Surgery. See tables 2-4 below for comparison data.




3.8 All areas who rated amber on a day or night shift took action to mitigate any risks to maintain patient safety. Appendix 3 provides the detail for the safe staffing exception report for July 2014, by division and ward, with mitigations to maintain safe staffing on the amber rated days.

3.9 A total of 795.5 band 7 supervisory hours were lost in the month of July mitigating unfilled hours to maintain safe patient care within the adult in patient wards. This will be monitored closely over the coming months to identify trends in clinical areas that may impact on the ability of the Band 7 to carry out their supervisory role and responsibilities.

4. Risks

4.1 There will be times when patients are admitted with higher acuity that require a higher level of staff than the agreed requirement, ie 1:1 nursing.

4.2 Data is currently sourced from both electronic and manual data entry to enable ratification of robust data collection. User error and administrative failure pose a risk to data quality.

5. Recommendations



· Note the ongoing work and actions

Tracey Carter Chief Nurse

15th August 2014

Appendix A

West Hertfordshire Hospitals Unify Fill rate indicator return Staffing: Nursing, midwifery and care staff July 2014

Day

Night


Care Staff


Care Staff

Day

Night

Site Code

Site Name













RWG03


1906

2056

892.5

1075.5

1207.5

1207.5

356.5

345

107.9%

120.5%

100.0%

96.8%

RWG02


50621

49377

25894

26552

44263.5

43711.5

18285

19136

97.5%

102.5%

98.8%

104.7%

West Hertfordshire Hospitals Unify Fill rate indicator return by ward July 2014

Appendix B Number of day and night shifts (includes long days early and late shifts) planned against actual on duty July 2014.

Please note the actual staff on duty would include staff unplanned but essential to maintain patient safety e.g. 1:1 specials and staff rostered and working clinically on a period of supervision (orientation). These staff would be in addition to the planned staffing levels and distort the actual required staffing levels

Division

Area

No. of Day Shifts

No. of NightShifts

No. of Day Shifts

No. of NightShifts

Planned

Actual

Planned

Actual

Planned

Actual

Planned

Actual



Medicine

AAU Blue Level 1

107

103

93

92

62

65

62

64

AAU Yellow Level 1

110

109

93

92

62

62

62

64

AAU Green Level 1

113

112

93

93

62

73

62

69

AAU Red Suite

113

113

93

93

62

64

31

33

AAU Triage

187

163

93

92

92

100

62

59

AAU Blue Level 3

128

125

124

122

93

91

62

61

AAU Yellow Level 3

113

113

93

90

62

65

31

40

AAU Green & Purple L3

166

164

124

121

124

127

62

67

Bluebell

145

146

124

125

124

125

124

127

Winyard

110

109

93

90

62

59

62

66

A&E

310

305

310

318

124

119

62

60

UCC Hemel

93

93

62

62

31

31

0

0

MIU SACH

62

62

0

0

0

0

0

0

Sarratt

173

184

155

146

155

188

93

151

Croxley

145

152

124

124

124

137

93

102

CCU

138

137

124

122

23

21

0

2

Cassio

115

113

93

92

62

85

31

55

Gade

112

114

93

92

62

76

31

42

Heronsgate

111

112

93

93

72

74

31

40

Aldenham

189

185

170

169

110

120

47

54

Acute Stroke Unit

235

231

217

216

93

128

93

94

Total

2975

2945

2464

2444

1661

1810

1101

1250

Surgery

Beckett

30

36

12

12

13

17

0

0

De La Mare

139

156

93

93

62

88

31

30

Letchmore

108

108

93

93

62

60

31

31

Flaunden

146

146

124

112

93

93

31

37

Ridge

143

145

93

87

93

86

62

62

Cleves

114

117

93

92

93

96

31

46

Langley

106

99

62

59

39

47

31

30

Combined ITU

472

457

451

452

31

28

29

26

Total

1258

1264

1021

1000

486

515

246

262

Women's & Childrens

Paediatrics

Starfish

116

119

93

85

31

33

31

27

CED

124

129

93

90

0

1

0

1

Safari Day Unit

62

67

0

0

23

18

0

0

Neonatal Unit

190

177

189

186

29

26

27

8

Transitional Care Unit

3

20

1

15

58

39

61

40

Gynaecology

Elizabeth

141

148

93

93

62

62

62

53

Maternity

Delivery Suite

333

318

279

274

62

69

62

45

Alexandra BC

124

120

93

92

31

35

31

25

Victoria

93

76

62

62

31

38

31

28

Katherine

155

153

93

91

93

81

62

51

Knutsford

31

30

31

31

31

31

31

25

Total

1372

1357

1027

1019

451

433

398

303

Appendix C

July 2014 Trust safe staffing exception report

Nursing & Midwifery Professional Judgement safe staffing RAG Rates

Green - Staffing numbers are as expected on the rota and ward is assessed as being safely staffed taking into consideration workload and patient acuity. Staffing numbers are not as expected but safe according to current workload.

Amber - Staffing numbers are not as expected and minor adjustments need to be made to bring staffing to a reasonable level given workload and acuity or staffing numbers are as expected but given workload and acuity additional staff are required.

Red - Staffing levels inadequate to cope with current patient needs.

Division

Area

Date

Shift

Professional Judgement Rag Rating

Comments, Mitigation - Actions taken to Ensure safe Staffing Levels

Medicine

AAU Blue L1

19/07/2014

Day

A

Band 7 to provide support to the staff

AAU Green L1

05/07/2014

Day

A

Down an RN in the day shift out to nhsp/agency not covered. Triage will help to support

17/07/2014

Day

A

Band 7 in the numbers till 3pm. 1x Pts on bipap. 18 iv medication and one nurse does IV's

AAU Triage

19/07/2014

Day

A

Band 7 to support in Triage

21/07/2014

Night

A

1 HCA down at night. Support from Green L1

22/07/2014

Day

A

2 nurses short for the long day, senior sister will be working in the number on long day. Extra hca

AAU Yellow L1

28/07/2014

Day

A

Band 7 to support.

29/07/2014

Day

A

1 RN down for the day shift. Band 6 in the numbers

Bluebell

14/07/2014

Day

A

Band 7 working in the numbers, Winyard ward to support as required

Winyard

22/07/2014

Day

A

x1 RN out to agency. Band 7 on late shift. Bluebell ward to support

A&E

18/07/2014

Day

A

PDN to support clinically no band 7. Medical staff to cover ANP workload. Trying to rearrange night ANP to come in early

22/07/2014

Day

A

enp needed to be sent to UCC to ensure UCC was safe.

31/07/2014

Day

A

staff moved to ensure all areas covered Clinical facilitator worked in the department. Agency nurses arrived very late.

Acute Stroke Unit

11/07/2014

Day

A

3 trained sick but 1 is covered by agency. 1 overseas nurse without PIN working as HCA. Currently 7 empty beds which helps with safety but will become more difficult if we start admitting. 1 HCA sent to support ward. No further trained staff available. maintained 8 empty beds throughout day but acuity reflects amber rating

Aldenham

19/07/2014

Day

A

nurse awaiting pin number - supernumerary working in the numbers

Cassio

06/07/2014

Day

A

1RN DNA on a LD; 1 CSW worked from another ward from 0945. 1 Special CSW LD and N

13/07/2014

Day

A

X 1 special Agency R/N DNA. NHSP informed, on duty were 2 sisters from the ward 2 CSW from the ward and senior nurse on call sent a Csw to ward

CCU

06/07/2014

Night

A

senior sister can be contacted for support, shift out to NHSP, Bed manager informed x1 RN short.

21/07/2014

Night

A

unconfirmed booking for agency HCA (LD). Band 5 swapped with HCA as Gade ward short. Band 7 can be contacted for support

29/07/2014

Day

A

1 staff nurse short, out to NHSP. Matron informed. Band 7 can be contacted for support.

Croxley

19/07/2014

Day

A

x2 specials booked but did not turn up for duty. Support from Sarratt ward

Gade

10/07/2014

Day

A

one HCA short on the LD and require special for LD CSW this was escalated to senior nurse no help available

12/07/2014

Night

A

1 HCA special for patient. 1 RN SHIFT OUT STANDING escalated to senior nurse no other staff member available to help.

21/07/2014

Day

A

Ward will be one RN down on the late shift due to cancellation by bank. Supervisory in the numbers

22/07/2014

Day

A

1 RN short was required for escort. No help available used ward staff, this left the ward short. This was escalated to senior nurse, no help available

Heronsgate

04/07/2014

Day

A

Have 2 patients that require 1:1, one patient has special book which has not been covered on NHSP, 2nd patient has become confused over night, after speaking with staff have requested special as they have needed staff memeber with her at all times. escalated to Matron, senior sister stepped into bay.

05/07/2014

Day

A

Extra HCA for special for confused staff. Agency nurse DNA shift, supervisory stepped into bay, escalated to matron

27/07/2014

Day

A

unfilled shift on long day it is out to agency, awaiting to see if it fills. Tried to move staff to cover unable to. Escalated to bed manager and on call sister.

Sarratt

19/07/2014

Day

A

RN cancelled long day. 3rd year student supported vacant shift

Surgery

ITU

15/07/2014

Day

A

Outreach nurse was required to work in ITU during day shift to support the unit.

19/07/2014

Night

A

x1 agency nurse cancelled late. Outreach nurse pulled out to work on unit. X1 agency ward trained nurse booked in to help.

21/07/2014

Night

A

Admitted ward patients as hospital full, unable to admit electives , outreach service suspended to take patients. Escalated to Matron +Site manager unit safe.. Night Comment: Outreach service should be re-established overnight. No capacity for level 3 admission. No level 1 patients on ITU.

26/07/2014

Night

A

Unit full with 19 patients no ward patients. Escalated to Matron . Staffing safe.

De La Mare

22/07/2014

Day

A

1 RN sick on a long day, covered the late shift and Beckett closing this pm and staff will come up to De la Mare

Flaunden

28/07/2014

Night

A

4th trained cancelled late pm with nhsp and not replaced. Took tap from ridge ward = 3 + 2

30/07/2014

Night

A

one RGN has cancelled at 03.30. was escalated on a5 authorised shift out to nhsp not covered. B2 spare overnight covered it via bed manager authorisation.

Letchmore

01/07/2014

Night

A

liaise with matron as senior nurse for night shift has commenced paternity leave which leaves only junior staff on the ward

05/07/2014

Day

A

One R.N short. Poor skill mix on ward and in ESAL, Bed manager made aware . Band 4 Tap Nurse on duty today. Additional R.N for late shift.

14/07/2014

Day

A

RN sick LD, escalated to matron, band 7 counted in numbers for early, HCA relocated from another ward, RN shift requested from NHSP

19/07/2014

Day

A

One HCA on Sick leave. Bleep holder and bed manager made aware at 20:00 on 18/7/14. Shift placed on NHS Professionals not currently filled. Shift time changed to 10:00, Shift to be "unlocked" for agency this morning. Will share 10:00 to 22:00 nurse with ESAU.

21/07/2014

Day

A

band 6 sick LD, band 7 counted in numbers early shift, will escalate to matron

25/07/2014

Day

A

1 RN sick LD, band 7 incuded in numbers AM, will escalate to matron

30/07/2014

Day

A

1 RN sick for LD, band 7 counted in numbers. 2nd RN in ESAU to work between ward and ESAU. 1 CSW is an assisted practitioner who can take a bay

Ridge

19/07/2014

Night

A

1 hca short,senior nurse on call informed. Healthcare from Langley ward assisted when needed

20/07/2014

Night

A

1 R/N short.Senior nurse on call informed. ,unable to get trained,extra hca sent by bleepholder during the night

Womens & Childrens

Paediatrics

CED

02/07/2014

Day

A

Risk mitigated by Senior sister and moving staff around the service.

14/07/2014

Night

A

Night out to agencies. Not filled but staff on ward and A&E aware and covered as required.

15/07/2014

Night

A

MLD out to agencies. A&E and Starfish aware and can help as required

18/07/2014

Night

A

Starfish and A&E aware, will support if needed. Senior Sister on call aware. Agency not filled.

20/07/2014

Day

A

MLD one staff nurse short due to sickness. A&E and Ward aware that help may be required.

22/07/2014

Night

A

out to agency. Agency filled

27/07/2014

Night

A

x1 member of nursing team on N is newly qualified, awaiting PIN. A&E and Starfish aware, will support if needed

Safari

23/07/2014

Day

A

Senior Sister assisting on ward

Starfish

09/07/2014

Night

A

Ced aware and able to assist through the night if needed .Senior nurse on-call available via telephone.

10/07/2014

Night

A

Night shift down to last minute sickness. Senior nurse on call aware and available by phone for advice.Ced available toprovide help if needed.

11/07/2014

Day

A

Staff sickness at short notice, x2 band 7's working on the ward to assist, CED and safari unit able to provide assistance where needed.

Gynaecology

Elizabeth

09/07/2014

Day

A

x1 HCA doing the housekeepers job. X6 electives to come in, only 1 bed at present. X1 medical management of miscarriage to bring in and the nurse special not filled for that.

14/07/2014

Day

A

Band 5 not covered and Band 2 DNA.Band 2 early for housekeper. Staff split to 2 bays each and all discharges/admissions to be completed by 2pm to mitigate risk from returning afternoon list

17/07/2014

Day

A

x1 RN shift outstanding. X2 medical managements of miscarriages coming in today and they are usually specialled and they will heighten the activity on the ward. Band 7 to assist on the ward

19/07/2014

Day

A

x1 RN phoned in sick in the night. X 1 HCA went off sick late last night. Supernumerary trained nurse awaiting pin supporting clinically, HCA cover for 7.5 hours of 11.5 hour shift

22/07/2014

Day

A

x1 HCA short. X 8 elective patients to bring in. Band 7 in the numbers

30/07/2014

Day

A

Only 3 nurses on the ward after 5pm. 6 electives to come in. 6 medical patients. 2 surgical patients. 4 breast patients. Supervisory in the numbers

Maternity

Delivery Suite

07/07/2014

Night

A

one RM short on shift , high levels of activity, sit rep changed at 22:00, called in community as 9 x labouring Patients , 1HDU and high risk an patient requiring 1:1,informed matron and community midwifery manager, 10 deliveries between 22:00 and 04:00 including admission of a high risk CSF case, with violent family connections and high flight risk. Safe staffing status now amber .

Appendix 3

Nursing and Midwifery Safe Staffing - Month 5

1. Purpose

1.1 This paper provides an update on the progress regarding the arrangements for managing safe nursing and midwifery staffing levels within the inpatient wards during August 2014.

2. Background

2.1 The Trust submitted all unify data to NHS England as required by the 9th September 2014 which is available to view on NHS Choices website at the end of the month. See Appendix A for August 2014 unify data by site and ward.


3.1 The Trust reported 1,633 unfilled hours for trained nurses and midwives and 1,124 hours unfilled against planned for health care assistants on day shifts. On night shifts 402 hours were unfilled for trained nurses/midwives against the planned hours required on duty, and for healthcare assistant 104 hours were on duty above planned hours.

3.2 Comparison data and trends overall in the Trust can be seen in tables 1-3 below. This comprises of all staff on duty including unplanned essential staff e.g. 1:1 specials. The overall fill rate shows a reduction from the previous month.

Table 1 – West Hertfordshire Hospitals - overall percentage of hours filled against planned

Table 2 – St Albans City Hospital - percentages of hours filled against planned

Table 3 – Watford General Hospital - percentages of hours filled against planned





3.3 Some clinical areas are noted to have an increase in hours above planned for health care assistants due to fluctuations in the acuity or dependency of patients on some shifts e.g. 1:1 specials and escorts.

3.4 Across all wards and departments there were 2,363 day and night shifts of these 2,261 shifts were rated green, 102 rated amber and 0 shifts were rated red. See appendix B for monthly detail by ward/department which also includes areas not in the unify data reporting.

3.5 There was a 1.6% increase in amber ratings during the month of August. See table 1 below for monthly trends.


3.6 The division of Medicine reported an increase in amber rated shifts of 1.6%, Surgery a decrease of 0.6% and Women’s and children’s an increase of 1.7% in August from the previous month. See tables 2-4 below for comparison data.




3.7 All areas who rated amber on a day or night shift took action to mitigate any risks to maintain patient safety. Appendix C provides the detail for the safe staffing exception report for August 2014, by division and ward, with mitigations to maintain safe staffing on the amber rated days.

3.8 A total of 862.5 band 7 supervisory hours were lost in the month of August mitigating unfilled hours to maintain safe patient care within the adult in patient wards. This was an increase of 67 hours on the previous months.

4. Risks

4.1 There will be times when patients are admitted with higher acuity that require a higher level of staff than the agreed requirement, i.e. 1:1 nursing.

4.2 Data is currently sourced from both electronic and manual data entry to enable ratification of robust data collection. User error and administrative failure pose a risk to data quality.

5. Recommendations



Tracey Carter Chief Nurse and DIPC

15th September 2014

Page 52 of 52

Appendix A

West Hertfordshire Hospitals Unify Fill rate indicator return Staffing: Nursing, midwifery and care staff August 2014

Day

Night


Care Staff


Care Staff

Day

Night

Site Code

Site Name













RWG03


1811

1782

862.5

998

1184.5

1173

345

345

98.4%

115.7%

99.0%

100.0%

RWG02


50078

48474

25951.5

24666.5

44631.5

44240.5

18147

18250.5

96.8%

95.0%

99.1%

100.6%

West Hertfordshire Hospitals Unify Fill rate indicator return by ward August 2014

Day

Night

Day

Night

Hospital Site Details

Ward name

Main 2 Specialties on each ward


Care Staff


Care Staff





Site code

Hospital Site name

Specialty 1

Specialty 2









RWG0


AAU Blue Level 1


1148.5

1064

713

724.5

1069.5

1058

713

690

92.6%

101.6%

98.9%

96.8%

RWG02


AAU Yellow Level 1


1122

12060.5

713

713

1069.5

1069.5

713

736

94.5%

100.0%

100.0%

103.2%

RWG02


AAU Green Level 1


1167

1097

713

724

1069.5

989

713

690

94.0%

101.5%

92.5%

96.8%

RWG02


AAU Red Suite


1219.5

1208

713

713

1069.5

1081

356.5

460

99.1%

100.0%

101.1%

129.0%

RWG02


AAU Blue Level 3


1441

1360.5

1069.5

1035

1426

1380

713

713

94.4%

96.8%

96.8%

100.0%

RWG02


AAU Yellow Level 3


1204.5

1166

713

690

1069.5

1058

356.5

356.5

96.8%

96.8%

98.9%

100.0%

RWG02


AAU Green & Purple Level 3


1787.5

1718.5

1426

1368.5

1426

1403

713

713

96.1%

96.0%

98.4%

100.0%

RWG02


Bluebell


1568.5

1522.5

1426

1380

1426

1414.5

1426

1460.5

97.1%

96.8%

99.2%

102.4%

RWG02


Winyard


1183

1075.5

713

713

1069.5

1023.5

713

724.5

90.9%

100.0%

95.7%

101.6%

RWG02


Sarratt


1932.5

2063.5

1658.5

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