SOMERSET PARTNERSHIP NHS FOUNDATION TRUST MANAGING THE NURSING RESOURCE - PART (2) REVIEW OF COMMUNITY NURSING SERVICES ESTABLISHMENT

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1 SOMERSET PARTNERSHIP NHS FOUNDATION TRUST MANAGING THE NURSING RESOURCE - PART (2) REVIEW OF COMMUNITY NURSING SERVICES ESTABLISHMENT Report to the Trust Board 28 January 2014 Sponsoring Directors: Author: Purpose Gareth Howells - Interim Director of Nursing and Patient Safety. Mary Martin Professional Lead for District Nursing, Clinical Lead for the overnight District Nursing Service. Dawn Dawson - Interim Head of Nursing. Gareth Howells - Interim Director of Nursing and Patient Safety. The purpose of this report is to: set out the context for ensuring nurse staffing levels within the Trust Community Nursing Services are safe and appropriate; identify the current establishment position within Trust Community Services of Somerset Partnership NHS Foundation Trust; recommended safe staffing levels; identify options which could be taken to address any shortfall identified; Links to Strategic Objectives: identify a preferred option to support the delivery of safe and efficient nurse staffing levels. to remain the provider of choice for community health, for the people of Somerset and for the wider South West ; to continue to improve the quality and safety of our services and to improve further the experience of patients, carers and families in contact with our services; to realise the benefits for patients and staff of the acquisition of Somerset Community Health; to value, support and empower all our staff and volunteers to do their best through education, training and personal development to deliver high quality services which are responsive to the needs of patients, carers and families; Managing the Nursing Resource Part 2 Review of Community Nursing Services Establishment January 2014 Public Board - 1 -

2 to promote innovation and service redesign based on best practice and working with partner organisations, to maximise efficiency and effective care in response to the major financial challenges facing the Trust, the wider NHS and other public and voluntary sector organisations. Links to the NHS Constitution: Links to CQC Outcomes: Quality of care and environment Respect, consent and confidentiality Complaint and redress. Relevant to all outcomes in the sections below: Information and involvement; Personalised care, treatment and support; Safeguarding and safety; Suitability of staffing; Legal or statutory implications/ requirements: Public/Staff Involvement History: Previous Consideration: Recommendation: Quality and management. implementation of Health and Social Care Act 2012 in respect of commissioning structures and requirements for greater transparency in quality of services and improved patient and public involvement; it is a requirement of the NHS Complaints Regulation that a regular report on complaints is provided to the Board. The report sets out information relating to patient experience of the quality of services and feedback from patients, carers and the public on the services the Trust provides, including patient surveys. This is the second paper presented to Trust Board in respect of safe staffing levels, but is the first specifically related to the Community Nursing Service. The Board is requested to discuss the report. Managing the Nursing Resource Part 2 Review of Community Nursing Services Establishment January 2014 Public Board - 2 -

3 Executive Summary 1. Recently there have been a series of media stories, which have highlighted incidents of poor patient care both in the NHS and in the private health sector. The reports generated from these incidents identify that the number of nursing staff on duty in clinical setting is a key factor in determining the quality of care provided. 2. This report sets out to clarify the current establishment position within the Community Nursing Services of Somerset Partnership NHS Foundation Trust; recommend safe staffing levels; identify recommendations which could be taken to address any shortfall identified. 3. The methodology for this review included determining the existing establishment for each community hospital inpatient area. Calculating the minimum safe staffing levels and benchmarked nurse staffing information for each inpatient area using key principles contained within the following guidance documents Guidance on Safe Staffing Levels in the UK and District nursing harnessing the potential - The RCN s UK position on district nursing, 2020 Vision - Focusing on the Future of District Nursing, Queens Nursing Institute. 4. The recommendations of this review advocate the following: as the report describes, the District Nursing service is committed to providing a safe, effective and efficient service however there are current challenges that pose a significant risk to current service provision. The recommendations set out below will help to reduce this risk; this includes management of ambulant patients. It is recommended that the CCG enable the District Nursing Service Specification to be applied by ensuring that services and patient groups that fall outside the specification have their needs met through other services; to manage increasing demand and complexity, it is recommended that further collaborative working with GP colleagues is undertaken to identify patient groups that could be managed differently and by other services; Managing the Nursing Resource Part 2 Review of Community Nursing Services Establishment January 2014 Public Board - 3 -

4 a phlebotomy service proposal has been drafted to transfer routine blood sampling for housebound patients and the point of care testing for INR to separate this function from standard District Nursing interventions. This will enable a more streamlined, cost effective approach. It is recommended that this proposal is supported and resourced; that further investment is considered to provide a FNC/CHC assessment team in each District Nursing federation to enable District Nurses to provide high quality assessments in line with the National Framework; further investment is considered to provide safe staffing levels are established that reflect increasing caseloads and complexity of care provided in the home environment; it is recommended that Shift patterns are standardised across all District Nursing Teams in order to provide a sustained consistent staffing level with a consistent skill set over the period; the District Nursing Service employs band 4 assistant practitioners who would be able to deliver a greater range of care thereby supporting the band 5s to deliver the more complex care and the band 6s to manage the team and provide clinical leadership. 5. The Trust Board are asked to note this review and support the recommendations identified. Managing the Nursing Resource Part 2 Review of Community Nursing Services Establishment January 2014 Public Board - 4 -

5 SOMERSET PARTNERSHIP NHS FOUNDATION TRUST MANAGING THE NURSING RESOURCE - PART (2) REVIEW OF COMMUNITY NURSING SERVICES ESTABLISHMENT 2014 Mary Martin January 2014 Managing the Nursing Resource Part 2 Review of Community Nursing Services Establishment January 2014 Public Board - 1 -

6 REVIEW OF COMMUNITY NURSING SERVICES ESTABLISHMENT 2014 CONTENTS 1 INTRODUCTION DISTRICT NURSING CURRENT ACHIEVEMENTS IN DISTRICT NURSING CHALLENGES FACING DISTRICT NURSING PRACTICE NURSES URINARY CATHERTIERISATION... 7 PROVISION OF CARE FOR TEMPORARY RESIDENTS / HOLIDAY MAKERS... 8 NEGATIVE PRESSURE WOUND THERAPY (VAC) PATIENTS IV THERAPIES OPTIONS FOR MANAGEMENT LEG ULCER CLINIC NO TRANSPORT AVAILABLE TO ACCESS THE GP SURGERY RECOMMENDATION CURRENT DEVELOPMENTS IN DISTRICT NURSING RECOMMENDATIONS SUMMARY REFERENCES.. 14 APPENCICIES ADDITIONAL BAND 5 FUNDING APPENDIX 1 15 CHC COSTINGS APPENDIX 2 16 VENAPUNCTURE COSTING APPENDIX 3 17 January 2014 Public Board - 2 -

7 DISTRICT NURSING ESTABLISHMENT REVIEW INTRODUCTION 1.1 Recent Department of Health statements indicate that future provision of services within the National Health Service will involve the transition of care from hospitals into the community. Changing requirements across the healthcare landscape has led to a rise in the number of patients and the complexity of needs which are now treated within the community. Predictions suggest that this trend will increase over time. 1.2 District nurses play a central and vital role in caring for housebound patients. Existing district nursing services are already providing care for the growing number of patients who require more complex care. Coupled with this there is a predicted decline in the number of qualified District Nurses, with a graduate specialist practitioner qualification. These key practitioners are central to leading the service through these changes. 1.3 The population of Somerset is estimated at 530,200.Outside of the main towns, the county is characterised by a dispersed pattern of settlement and a low population density. This means that the District Nursing service cares for a dispersed population across a wide geographical area which results in significant travel across the county. 1.4 The main purpose of this review is to identify the current challenges facing by the service and to share the future strategic vision for District Nursing in Somerset. Recommendations are made in response to the identified challenges. 2. DISTRICT NURSING 2.1 District Nursing has been in existence for more than 150 years and remains relevant today. The original values and beliefs of District Nursing remain true within the county: the importance of keeping people at home where they want to be; the relationship between nurse and patient as the prime therapeutic tool; the need to work with the whole family and their carers as a unit; the importance of expert assessment and clinical nursing care; close working with other colleagues across health and social care; January 2014 Public Board - 1 -

8 the need to promote coping and independence. As already stated discharge prevention or early discharge mean the needs of the population have changed. Increasing life expectancy has resulted in a greater proportion of people living with chronic disease and frailty. Other variables have also impacted the District Nursing Service. Specifically: advances in medical technologies; increased patient expectation; economic climate and the need to maximise the use of resource; new commissioning and provider models. 2.2 There are key principles to be upheld: effectiveness district nurses need to ensure an easily accessible and responsive service across all geographical areas; integration the District Nursing Service must work in partnership with other services to help meet the individual s needs; efficiency the Service needs the right staff skill mix and must be well led; expertise the Service requires District Nurses to have expert professional skills to nurse people safely at home; caring - the Service must embrace and deliver care against the values and behaviours that underpin the 6Cs. 3. CURRENT ACHIEVEMENTS IN DISTRICT NURSING This review will firstly detail examples where District Nursing in Somerset has taken the lead in developing new and innovative ways of working in line with key national documents identified in Section 8. Secondly, the review will detail the resource, workforce and professional challenges that need to be considered to deliver the required service. Federation based District Nursing 3.1 Somerset is divided into nine GP Federations. Somerset Partnership NHS Foundation Trust have been working closely with these Federations to agree a new Federation based model for the District Nursing Service by aligning District Nursing teams with each GP Federation. This will ensure continued partnership working across professions. January 2014 Public Board - 2 -

9 Each Federation has a main hub which provides the single point of access for referral, nurse triage and administration for the Federation. Some Federations also have smaller offices, 'spokes' to enable the nursing teams to effectively cover the very rural county of Somerset. Currently six out of the nine District Nursing Federations have gone live with the new model. Benefits of the District Nursing HUB: a geographically specific approach to service delivery to reduce valuable nursing time lost in travel; triaging of referrals through a single point of access maximising efficiency; making every contact count - providing opportunistic advice and support to patients and their carers; strengthened communication with other providers thereby supporting transition of care including supporting discharge planning; strengthened collaborative working across agencies to support care; managing risk through strengthened professional support to nurses working in the community; new technology to strengthen team working within District Nursing Federations and support caseload management; standardisation of practice across the county; strengthening the values and behaviours of District Nursing using the 6 Cs to underpin the service and delivery of care. Caseload Capacity/Demand 3.2 Since April 2013 District Nursing caseloads have been held on RIO (electronic clinical system). All referrals and appointments to see patients are made through this clinical system. Following a patient visit or interaction the Health Care Professional records the outcome on RIO. This allows centralized reporting of referrals to caseloads, number of discharges, number of appointments and type of appointment. The system will provide robust data which will be invaluable in understanding caseload activity by team and by Federation. A caseload capacity tool has recently been introduced to the District Nursing teams to match capacity against demand for new referrals and to provide ongoing care on a daily basis. This information will be used to determine if skill mix and staffing levels in the federation meet service need. January 2014 Public Board - 3 -

10 Assessment Teams 3.3 Referrals to the District Nursing Service for Funded Nursing Care (FNC) and Continuing Health Care (CHC) assessments and reviews are increasing. The District Nursing Teams have worked extremely hard to meet the national 28 day completion target for the Continuing Healthcare process. To support this growing activity assessment teams are being developed in each Federation, this allows up skilling of Band 5 community nurses and provides a consist quality of assessment. The assessment team will use RiO to hold the FNC/CHC caseloads and manage their workload. Bridgwater Bay have an established assessment team and other areas are developing the model. ONPOS 3.4 Somerset Partnership NHS Foundation Trust has worked with the Clinical Commissioning Group to reform the supply of wound dressings to named patients. The use of FP10 can lead to delay in commencing treatment, significant wastage of patient specific dressings which cannot be re-used, allows a degree of non-compliance with the Somerset Wound Formulary, and is an inefficient use of GP and nurse time Wound dressings are purchased directly as a stock item by the Trust and the District Nursing service issues appropriate dressings to each patients as and when required. This is done through a system called ONPOS. This software ordering system provides real time data on dressing use and spend, and supports wound formulary compliance. Bridgwater Bay and West Mendip have already gone live with this system and are demonstrating improved quality of care as well as cost effective treatment. There is a programme of roll out to the other federations as they go live with the federation model. Band 5+ Development Role 3.5 Historically, teams would have consisted of a District Nurse, community staff nurses and a number of health care assistants. The latest data from the NHS Information Centre shows that the number of trained District Nurses has been falling for more than a decade (QNI, 2011). Prior to 1 August 2004 to qualify as a District Nurse a community staff nurse would complete a degree level educational programme within an approved higher education institution resulting in an NMC recordable qualification. The NMC is clear that there is no longer a requirement for a recordable District Nursing qualification and therefore an educational programme specific for District Nursing is no longer appropriate. As a consequence both the funding and strategic support for degree courses has been withdrawn in the south west. In response, the trust has built on the work of neighbouring organisations and developed a competency based approach to Community Nursing (Developmental Role band 5+). 15 band 5 staff nurses have currently entered the programme. 9 staff have now completed the programme and are working successfully as band 6 team leaders. The remaining 6 staff are all doing well and will complete within the 2 year programme. January 2014 Public Board - 4 -

11 Countywide Overnight District Nursing Service 3.6 The Overnight District Nursing Service provides nursing care to patients at night in their own homes and has historically been provided as an on call service in the East of the County and a waking night service in the West of the County. Somerset Partnership Foundation NHS Trust has now moved to a county wide waking night service with a Registered Nurse and a Health Care Assistant based in 3 locations across the county. These staff are able to respond to urgent calls throughout the night. 3.7 This change has resulted in an equitable provision of night nursing service throughout the county and supports the operational challenges facing the District Nursing Service: an increased number of referrals to the service; patients being discharged earlier from hospital; patients having a greater complexity of care needs; the need to support carers throughout the night with End of Life Care. 4. CHALLENGES FACING DISTRICT NURSING Caseload Capacity/Demand 4.1 Despite the introduction of Federation based nursing to maximise resource, the workload and complexity of patients continues to increase and teams report the workload is difficult to manage. Concerns have been raised countywide: a Senior District Nurse reports her teams have become very task orientated due to the increased amount of daily patient visits. Staff are not looking at the holistic needs of the patients which leads to more problems occurring; a Community Staff Nurse reports she no longer has time to discuss concerns as she is rushing to between different addresses in a 7.5 hour shift; staff have reported feeling unsafe and are concerned they will make mistakes; an increase of incidents reported on Datix has been noted. A Senior District Nurse believes that this reflects a tired workforce making more mistakes rather than improvement in reporting mechanisms; staff are consistently working additional unpaid to meet patient needs; a Senior District Nurse has reported that documentation is not of the standard expected by the Trust. January 2014 Public Board - 5 -

12 Federation Caseloads Referrals Discharges Appointments O District Nursing requires sufficient establishment to provide safe effective care. Nationally, there is limited data available for nurse staffing levels in the community. Existing data from other regions must be treated with caution to ensure that benchmarking is valid definitions of numerators (number of staff) and denominators (populations served) can vary hugely. District Nursing caseloads in Somerset are held on RIO.Table 1 gives an overview of data for November 2013 including WTE band 5 per Federation. Table (1) Funded WTE Band 5 Funded WTE Band 5 Assessment Team Bridgwater Bay North Sedgemoo r Taunton West Somerset South Somerset CIC West Mendip East Mendip Central Mendip Minimum staffing levels required to meet demand could be based on West Mendip Federation s data as they report they are managing their caseload (highlighted in Table 1) provided there is no sickness or annual leave. It is acknowledged that this is a crude assessment but if this is used as a basis for comparison an estimate can be given of caseload per WTE band 5 per federation as presented in table two. January 2014 Public Board - 6 -

13 Table (2) Federation Caseload per WTE band 5 Bridgwater /Bay 53.9 North Sedgemoor 56.7 Taunton 68.2 West Somerset 82.9 South Somerset 63.1 CIC 79.1 West Mendip 58.6 East Mendip 78.8 Central Mendip 75.1 If the West Mendip caseload is used as the appropriate staffing level then every 58.6 patients on the caseload requires 1.0 WTE band 5. Taking this model as the baseline then further funding is required where caseloads are above 60 patients per WTE band 5 across the county (as highlighted above in Table 2). It should be noted that this measure is a blunt instrument and it must be acknowledged that each federation is affected by wider determinants of health as measured by the deprivation indices. Table three outlines the extra resource required for the highlighted Federations to reduce their caseloads to 60 per WTE band 5. Table Three Federation Current WTE band 5 Required WTE band 5 CIC West Somerset Central Mendip East Mendip Taunton South Somerset Extra WTE band 5 resource required Costs for ensuring that caseloads are not above 60 per 1.0 WTE band 5 for each federation total 652,313 (Appendix 1) As well as determining the correct establishment levels there is also a need to maintain a sustained consistent staffing level with a consistent skill set over the period. This is to manage the increased levels of dependency and associated complex care. It has been recognized that many core functions and opportunities to practice and develop skills occur during day shifts. Nurses working solely on a current twilight shift have difficulty maintaining their competency and continuous January 2014 Public Board - 7 -

14 professional development requirements, they can become isolated and do not benefit from effective team working. Shift patterns are not consistent in District Nursing Teams across the Trust. It is therefore proposed that the Trust should now take the opportunity to standardise the shift patterns across all District Nursing Teams Venepuncture 4.2 The District Nursing Service provides community domiciliary phlebotomy and POCT for INR monitoring across the county for housebound patients. This provision is not consistent across the county. In some areas, this is only provided for patients on the District Nursing caseload with an identified nursing need whereas in other areas the District Nursing Service routinely offer phlebotomy for house bound patients. A review of the service specification for the District Nursing service resulted in the development of a business case for a domiciliary phlebotomy service. This would protect registered nurse time for delivering complex care and assessments rather than using this time for routine venepuncture. The business case proposes a separately resourced service utilising band 3 Phlebotomists with appropriate training and competencies and clear line management, supervision and mentorship structures. Total cost for the venepucture element of the phlebotomy service is 161,460. The District Nursing Service currently receives payment for the POCT for INR monitoring service. A contract payment of per patient, based on a caseload of 550 patients was originally calculated to cover the costs associated with nursing time, travel and consumables. However, activity data for the period April Oct 13 shows a 70.5% increase in the caseload above the funded figure. As a result the majority of the full year funding has already been allocated for consumables and nurse time. Retrospective funding to the additional caseload has been requested as agreed by the Clinical Commissioning Group in February Ambulant Patients 4.3 The new District Nursing specification states that the service is for housebound patients who require nursing care. Care is currently provided by the District Nursing service to a significant number of ambulant patients as other services are not available 7 days a week over 24 hours, or because they do not have the level of skills required to deliver the care. Following the development of the revised service specification for District Nursing in June 2012, it became apparent that certain services would no longer be provided through the new service specification. These are now January 2014 Public Board - 8 -

15 referred to as the orphaned services. There is significant variation on the type and extent of services displaced by the new specification across the federations. These are detailed below-: SERVICES AND LOCATIONS CURRENTLY PROVIDED THAT ARE NOT INCLUDED IN THE NEW DISTRICT NURSING SERVICE SPECIFICATION Services Currently Provided Weekend/bank holiday dressing clinic for practice nurse patients Practice nurse patients seen in their own homes at weekends/bank holidays Practice Nurse patients seen because there is no Practice Nurse on duty Practice Nurse patients seen because the intervention (complex wounds) take too long (>30 minutes) Clinic for ambulant patients with urinary catheter Ambulant patients with urinary catheters seen in their own homes Ambulant patients on holiday Ambulant vac therapy patients Diagnostic tests for housebound patients where there are no nursing needs Leg ulcer clinics B/Bay North West Taunton S moor Som YES YES YES YES South Som CIC West M dip East M dip YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES Central M dip YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES POCT testing INR monitoring in Nursing Homes Ambulant patients where there is no access to transport Ambulant IV therapies YES YES YES YES YES YES YES YES YES January 2014 Public Board - 9 -

16 DETAILED DESCRIPTION OF ORPHANED SERVICES 5. PRACTICE NURSE PATIENTS Practice Nurse Patients At Weekends And Bank Holidays 5.1 It is accepted that patients that attend the GP Practice Monday to Friday may on occasion need to be seen at weekends and on bank holidays. This is mainly for wound dressing changes. 5.2 Currently the practice nurse makes a referral to the District Nursing Service for this nursing care as the GP practice is not open at the weekends or on bank holidays. 5.3 Referral to the District Nursing Service for this nursing intervention occurs in all nine federations. Four of the federations hold weekend clinics to accommodate this work. These are Taunton Deane, West Somerset, North Sedgemoor and Bridgwater Bay. There is no appointment system. Patients are asked to arrive at the opening time and then will wait to be called. 5.4 It should be recognised that these patients are mobile and attending the surgery during weekdays.patients who are seen at home during weekend/bank holidays are informed that the nurse will make a morning home visit however timed visits cannot be given due to the nature of the core District Nursing work and urgent calls coming through during the weekends/bank holidays. The work is variable and unpredictable. It is difficult to estimate staffing levels required to accommodate this work as often the referrals will not come through to the District Nursing Service until Friday, following a Practice Nurse appointment Practice Nurse Patients When No Practice Nurse Is Available 5.5 This affects West Mendip Federation and Chard, Ilminster Crewkerne and West Somerset Federation. The District Nursing Service will be asked to see and treat patients at home if there is no Practice Nurse available on week days (Monday Friday). Practice Nurse Patients Who Require An Intervention That Lasts Longer Than 30 Minutes 5.6 In South Somerset, Chard, Ilminster and Crewkerne and West Mendip Federations the Practice Nurses cannot always accommodate patients that need a longer appointment than the allocated appointment slot. These patients are then referred to the District Nursing Service for treatment. 6. URINARY CATHETERISATION 6.1 Ambulant patients requiring urinary catheterisation are currently being seen at home by the District Nursing service in all nine federations to varying January 2014 Public Board

17 degrees. Three GP federations - North Sedgemoor, West Somerset and West Mendip run urinary catheter clinics. 7. PROVISION OF CARE FOR TEMPORARY RESIDENTS / HOLIDAY MAKERS 7.1 Five out of the nine federations are providing a home visit for ambulant holiday makers. 8. NEGATIVE PRESSURE WOUND THERAPY (VAC) PATIENTS 8.1 Six out of the nine federations are providing home treatment for ambulant patients requiring negative pressure wound therapy 9. IV THERAPIES 9.1 The District Nursing teams in the Mendip Federations and Bridgwater Bay are visiting ambulant patients at home for IV therapies. 10. OPTIONS FOR MANAGEMENT 10.1 Ambulatory Care Unit The planned activity as indicated in the list above could be safely delivered within an ambulatory care unit utilising the skills of the ambulatory care staff with medical responsibility remaining with the GP. Consideration for five ambulatory care settings across the county would enable patients from any Federation to arrange a convenient appointment time by contacting the ambulatory care unit direct of their choice. The service would need to be provided 7 days a week. For patients who require repeat appointments this could be arranged whilst they are in the unit. The team would monitor nonattenders and make contact with them to offer further appointments. They would also let the referrer know when planned care has not been delivered. 11. LEG ULCER CLINIC 11.1 The Chard/Ilminster/Crewkerne District Nursing team are currently running a leg ulcer clinic once a week at Chard Hospital for ambulant patients. In all other federations is now provided by the practice nurses An option for this clinic would be that Somerset Partnership NHS Foundation Trust is formally commissioned to run this clinic in Chard and provided by Somerset Partnership leg ulcer service. January 2014 Public Board

18 12. NO TRANSPORT AVAILABLE TO ACCESS THE GP SURGERY 12.1 Ambulant patients are referred to the District Nursing Service where there is limited access to public transport in some parts of Somerset, notably, West Somerset If District Nurses are to serve a population with high travel requirements between rural locations due to lack of public transport, an option is to fund additional community nursing staffing levels in this area. 13. RECOMMENDATION 13.1 Consideration should be given to each of these areas of service which will be displaced when the new District Nursing Specification is launched. Draft options for consideration have been included Further work to confirm activity levels and cost each of the options needs to be completed. FNC/CHC Assessment Teams 13.3 Referrals to the District Nursing Service for Funded Nursing Care (FNC) and Continuing Health Care (CHC) assessments and reviews are increasing. The District Nursing Teams have worked extremely hard to bring the Continuing Healthcare process in line with national requirements for completion within 28 days. To support this growing activity assessment teams are being developed in each Federation. The assessment team will hold all the FNC/CHC caseloads on RIO and use the interactive worksheet to organise their work. The benefits of having an assessment team per Federation are already becoming evident in Bridgwater Bay Federation. Bridgwater Bay has a dedicated team for FNC/CHC assessments. Feedback from staff in the assessment team has been positive as they can concentrate on the assessments from start to finish without being pulled away to undertake other clinical work. This has ensured a quality assessment completed in a timely manner. The team has also built up good working relationships with the nursing homes as they provide a consistent approach to the assessment process. The South West Commissioning Support Unit FNC/CHC team has given positive feedback regarding the quality, timeliness and consistency of assessments. Nursing Homes by Federation 13.4 Table one shows the number of residents in Nursing Homes in each Federation. This data is from August January 2014 Public Board

19 Table One B/Bay North Sedgemoor Taunton West Somerset South Somerset CIC East Mendip West Mendip Central Mendip Hours Required per Assessment Team per Federation 13.5 Each patient in a nursing home will need at least one annual review however as patients are living longer care needs are becoming more complex therefore some patients need more frequent reviews. The level of detail and evidence required for each assessment has also increased. On average it takes one day to complete an assessment if there are no interruptions in the process and there is administrative support Table two shows the number of WTE required for each assessment team. To increase efficiency the teams have been combined in some areas. Table Two Federation Band 6 WTE Band 5 WTE BAND 2 (ADMIN) WTE B/Bay/North Sedgemoor combined Taunton and West Somerset combined South Somerset CIC East Mendip/Central Mendip/West Mendip combined Costs for providing CHC assessments teams across the county total 616, CURRENT DEVELOPMENTS IN DISTRICT NURSING 14.1 The Importance of Technology to Promote More Effective Mobile Working remote work scheduling; allocation of appointments done in advance to mobile devices will allow staff to receive pre-triaged and prioritised workload without coming to base; January 2014 Public Board

20 mobile devices will deliver greater efficiency, allowing more time for face to face patient care and cost savings on travel. It will also improve patient safety as there will be access to the patient s clinical record at point of contact and staff safety as there will be immediate information available on risks; E-messaging to GP records will ensure timely communication with GPs; read access to GPs records via Emis Web will enhance assessments. Ensuring We Have The Right Staff, With The Right Skills In The Right Place 14.2 Complex care once only delivered in acute settings is now being provided by district nursing teams. Band 2 and 3 healthcare assistants are not experienced or qualified to visit all patients, it would be more cost effective to employ band 4 assistant practitioners who would be able to deliver a greater range of care thereby supporting the band 5s to deliver the more complex care and the band 6s to manage the team and provide clinical leadership. Due to the increasing demand, Band 4s should be in addition to (rather than a skill mix of) Band 5s. 15. RECOMMENDATIONS 15.1 As the above describes, the District Nursing service is committed to providing a safe, effective and efficient service however there are current challenges that pose a significant risk to current service provision. The recommendations set out below will help to reduce this risk This includes management of ambulant patients. It is recommended that the CCG enable the District Nursing Service Specification to be applied by ensuring that services and patient groups that fall outside the specification have their needs met through other services A phlebotomy service proposal has been drafted to transfer routine blood sampling for housebound patients and the point of care testing for INR to separate this function from standard District Nursing interventions. This will enable a more streamlined, cost effective approach. It is recommended that this proposal is supported and resourced It is recommended that further investment is considered to provide a FNC/CHC assessment team in each District Nursing federation to enable District Nurses to provide high quality assessments in line with the National Framework. January 2014 Public Board

21 15.5 It is recommended that further investment is considered to provide safe staffing levels are established that reflect increasing caseloads and complexity of care provided in the home environment It is recommended that Shift patterns are standardised across all District Nursing Teams in order to provide a sustained consistent staffing level with a consistent skill set over the period It is recommended that the District Nursing Service employs band 4 assistant practitioners who would be able to deliver a greater range of care thereby supporting the band 5s to deliver the more complex care and the band 6s to manage the team and provide clinical leadership. 16. SUMMARY 16.1 The District Nursing service is facing increasing demands due to the volume and complexity of patients in the community. Resource transfer needs to keep pace with these demands in order that capacity to manage these cases is targeted in the right area. The District Nursing service currently demonstrates the ability to recruit and innovate to achieve high quality outcomes for patients. 17. REFERENCES Vision and Values, a call for action on Community Nursing (QNI, 2006); 2020 Vision (QNI, 2009); Guidance on safe nurse staffing levels in the UK (RCN, 2010); Care in local communities (DoH, 2013); District Nursing harnessing the potential (RCN, 2013). January 2014 Public Board

22 Additional Band 5 Funding APPENDIX (1) District Nursing Staffing Federation Current WTE Required WTE Extra WTE band 5 Cost of additional Band 5 Band 5 Resource required Resource required CIC ,109 West Somerset ,623 Central Mendip ,900 East Mendip ,269 Taunton ,541 South Somerset , ,313 Total January 2014 Public Board

23 January 2014 Public Board Appendix (2)

24 Appendix (3) January 2014 Public Board

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