Date: Click here to enter a date. Staffing for Safety and Quality Report July 2016

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1 Quality Committee Agenda Item Report Title FOIA Exemption Prepared by Presented by Action required Date: Click here to enter a date. Staffing for Safety and Quality Report July 2016 No Exemption Lynne Carter, Interim Deputy Director of Nursing David Mulligan, SafeCare Project Lead Lynne Carter, Interim Deputy Director of Nursing Noting Supporting Executive Director Executive Director of Nursing and Quality PURPOSE OF THE REPORT: Report purpose To provide the Quality Committee with: An overview of the recommendations of the Carter Report on staffing. An update on LCFT actions in relation to the Carter Report. An update of the Staffing for Safety and Quality Group actions to be noted by the committee in relation to improvements to the Safer Staffing report. Assurance of actions being taken to improve safety and quality in the delivery of care to people who use our services. Board Assurance Framework risk CQC domain To provide high quality services 1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services. Safe

2 Staffing for Safety and Quality January to June Introduction Nationally, safer staffing is a high profile challenge and there is significant evidence which supports the premise that in order to provide high quality, safe care, trusts require not only the right number of staff but also that they are educated, supported and developed. The Department of Health commissioned a report which was published in 2015 entitled Operational productivity and performance in English NHS acute hospitals: Unwarranted variation. An independent report from the Department of Health by Lord Carter of Coles (Carter report) this report highlights a number of opportunities where nursing, midwifery and allied health professional (AHP) colleagues can make a contribution to delivering high quality care in a sustainable way for patients and their communities. Whilst the initial focus was on acute hospitals the issues are the same for community, mental health and learning disability services in relation to staff and the safety and quality of care. The Carter report made three recommendations. These were that all trusts should: Implement an effective approval process by publishing rosters six weeks in advance and reviewing against trust key performance indicators such as proportion of staff on leave, training and appropriate use of contracted hours; Set up a formal process to tackle areas that require improvement, with escalation paths, action plans and improvement tracking; Develop the associated cultural change and communication plans to resolve any underlying policy or process issues. All trusts should aim to implement these recommendations by December NHS Improvement (NHSI) which is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams developed Good Practice Guidance: Rostering which was circulated to all Directors of Nursing at the beginning of July 2016.

3 This guidance informs the assurance process with specific recommendations for key performance indicators (KPIs). 2. Lancashire Care NHS Foundation Trust (LCFT) Staffing for Safety and Quality In LCFT safer staffing and the assurance of quality of care provided is reported through multiple metrics. In May 2016 some of the more significant metrics were brought together to triangulate staffing, safety and quality. The information was shared back into the Networks to begin a more robust assurance process. Feedback was requested from the Quality and Safety Sub-Committee and the Joint Quality and Performance Sub-Committee on the initial report reflecting April 2016 data. Almost immediately the report stimulated questions regarding the impact of existing staff numbers and also areas relating to core skills compliance and the use of temporary staff in LCFT in-patient wards and units. Individual areas have begun to identify anomalies and the data is now becoming more robust. This LCFT report covers the majority of the recommended KPIs from the Carter Report and additional KPIs will be included in all future reports. It should be noted that the report does not contain a full 6 months data across all metrics as some of these have only been collected recently. This means that the trend analysis is skewed or not available for all metrics and should be viewed with that in mind. It is anticipated that the metrics used may change over time, particularly in regard to indicators relating to patient outcomes. Action point: all metrics will be included from July LCFT is already in a good position in regard to the Carter report recommendations and it is anticipated that LCFT will achieve these by the end of The planned further roll out of electronic rostering will also support future analysis and more timely feedback. At present there are RAG ratings for some of the individual metrics of the Staffing for Safety and Quality Analysis Report (SSQAR) and where applicable these have been used. The reference data ranges are attached at Appendix 1. An overarching RAG rating for ease of reporting overall assurance is in development. Action Point: RAG rating complete by the end of August This report covers the in-patient areas of LCFT and a roll out is planned for the community and other services.

4 The link between patient and staff satisfaction and high quality care are well known and LCFT reports on these metrics regularly. This report enables access to a range of these metrics in one place and allows greater transparency plus the identification of trends, themes and hot spots. The areas triangulated are: Staffing - includes care hours per patient day; rostering; establishment; vacancies; absence; beds; acuity and dependency; temporary staff, SafeCare Safety - includes Harm Free Care; incidents; core skills compliance Quality - includes patient experience; complaints; compliments. Each of the above areas has specific KPIs attached to them and these are monitored at ward level and through the Staffing for Safety and Quality Group. Areas of good practice and concerns are reported by exception together with any actions required and learning to be shared. The report is produced and circulated monthly and overall trend analysis graphs for some areas of the report for January to June 2016 are available. This trend analysis is still in development and the graphs in this report are being used to enable more information to be sought before assurance can be taken from them. This is provided month on month by ward for the Networks. 3. Current information Dashboards for in-patient areas from January to June 2016 are attached at Appendix 2. Composite trend analysis graphs for some of the metrics are included in the body of this report. Electronic rostering - LCFT has already begun the implementation of electronic rostering and a business case is in development to ensure full implementation and benefit analysis. This work also feeds into the workforce planning and financial stability of the trust. Friends and Family Test - whilst the Trust reports on this in line with the national reporting framework it has not been possible to complete this for individual areas to date. The Quality team are changing this process to enable this to be added for future reports.

5 SafeCare - from November 2015 to March 2016 the e-rostering team, in collaboration with clinical teams successfully deployed the SafeCare module of HealthRoster, this enables staff to assess the acuity and dependency of their patients using an evidence based model which is nationally recognised. This is still relatively new to staff in some areas and similar models are being developed in relation to other service areas. Close monitoring of this is in place by the Matrons and support is available for ward sisters. There is a plan for the roll out of this module to other teams in LCFT. Bed occupancy - it is recognised that as wards change and patient dependency fluctuates there may be historic staff establishments which require amendment. This is also affected by bed occupancy which has a target of 85%; wards are established for this level. However most wards are significantly over this and have to utilise temporary staff to maintain safe staffing. At present the data on this for the in-patient areas is subject to fluctuation, however will be included as a metric from July Variance between patient demand and established hours - there is significant variance across the wards in this area regardless of their specialism. This may be due to patients being unable to be moved to an appropriate care area or to rapidly changing dependency. Mitigating actions are in place and this area is being closely monitored. Vacancies - active recruitment is in place and is monitored monthly to enable action to be taken, this is both a national and local problem and is actively being managed within LCFT. Appropriate use of contracted hours - LCFT electronic rostering process has the ability to report on this metric, however it is not yet a formal part of the analysis report but will enable much closer scrutiny of temporary staff need. This will also allow further monitoring of handover time, study leave allocation and shift patterns and will inform changes across the trust. Action point: contracted hours will be included from August 2016

6 Care hours per patient day- nationally in acute trusts there is a requirement to report Care Hours per Patient Day (CHPPD), whilst this is not yet a requirement for LCFT services the trust recognises that there is a benefit in assessing and monitoring this, however the nature of our multidisciplinary services means that the trust has an opportunity to influence further work and a plan is being developed to undertake a pilot project in LCFT. 20 Trend of CHPPD Delivered Jan to June January February March April May June 00. Monthly Total The trend analysis shows significant increases as more areas now monitor this, however as yet there is no national benchmark for this area in relation to our services. The trust is now engaging with partners to progress this work.

7 Temporary staffing fill rates LCFT in common with many others has a target to cap agency use and also recognises that an over reliance on temporary staff can affect the quality of care delivery. It has been recognised that booking staff at short notice affects fill rate and whether bank or agency staff are used. The SSQAR requires close scrutiny to develop action plans to reduce the reliance on temporary staff and ensure appropriate fill rates where necessary. LCFT has made positive changes to recruitment and retention of staff which will impact on this area and there is close scrutiny of this within the Networks % Trend of Shift Fill Day and Night % Jan to June % % % % % 80.00% 60.00% 40.00% 20.00% 0.00% January February March April May June 00. Monthly Total Sum of Day: Avg. fill rate - registered nurses (%) Sum of Day: Avg. fill rate - care staff (%) Sum of Night: Avg. fill rate - registered nurses (%) Sum of Night: Avg. fill rate - care staff (%) The current trend analysis shows an increase in fill rate for day and night duties for care staff however the fill rate for day duty registered nurses has not improved, this may lead to an overuse of care staff with a subsequent pressure on the existing registered nurse workforce. Further analysis is taking place.

8 Shift Fill % split by Bank & Agency Jan to june % 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% January February March April May June 00. Monthly Total - Sum of Bank 00. Monthly Total - Sum of Agency This graph displaying the split of temporary staff use by bank and agency shows that there has not yet been a significant change in the move to increased bank and decreased agency. Further work is in place to increase the recruitment of permanent and bank staff to reduce reliance on agency staff across the trust. Sickness absence - this is monitored across LCFT, however, this report enables visibility of ward based information in order for focused action plans to be put in place. An example of additional support is at the Harbour where an HR business partner has been based full time to support Matrons and ward sisters to better manage all areas of HR practice including sickness.

9 Core skills compliance - this is not yet at target across LCFT, this report gives visibility at ward level of the current position. An action plan is in place and monitored weekly to rectify this. Further work is now being carried out to assess competency in practice following training. Harm free care - the national Harm Free Care programmes focus on physical health and mental health respectively concentrating on a collection of common harms which clinical consensus determines as being largely preventable through appropriate care. The harms are: Physical Health related harms from: Pressure Ulcers Falls Catheter acquired urinary tract infections Venous thromboembolism Mental Health Related harms from: Restraint Violence and aggression Self-harm Psychological safety (feeling safe) Medication omissions This metric is a significant indicator of the quality of care and allows detailed quality improvement plans to be produced in each area to improve care for all people who use LCFT services. There is not yet enough data to show a trend analysis graph.

10 Charge nurse supervisory capacity - LCFT currently establishes 100% supervisory time for all in-patient area charge nurses in order for them to ensure robust management and leadership in practice % 90.00% 80.00% Trend of Monthly Charge Nurse Supervisory capacity 87.00% 90.89% 92.27% 87.97% 81.18% 91.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% January February March April May June 00. Monthly Total The report trend analysis shows that this is not always achieved and further analysis is required to clarify the impact of this position.

11 4. Next steps A review has commenced of the supporting processes needed to deliver improvements, these include: Shift patterns Rostering policy National benchmarking Shift by shift assurance Escalation process A comprehensive project plan with timescales and monitoring arrangements will be completed by the end of August 2016 which will then be presented to the Quality Committee. 5. Conclusion The SSQAR is enabling meaningful conversations and deeper investigation into individual areas to support changes which will improve safety and quality and this is in line with the Carter recommendations. LCFT staff are actively engaged in improvement work which supports quality improvements in patient care and assurance towards the goal of right care, right place, right time, every time. 6. Recommendation The committee is asked to note the report and support the further developments proposed.

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