Setting Nursing and Midwifery Budgets 2012 / 13

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1 Setting Nursing and Midwifery Budgets 2012 / Introduction This paper sets out the advice of the Director of Nursing, Midwifery and Patient Services in setting the budgets for nursing and midwifery teams within the Health Board. The main focus of this paper, and of concern at present, are the adult general wards within the District General Hospitals. Work is being undertaken separately with regards to staffing in the outpatient setting where the skill mix ratio will differ to that in an inpatient ward. Reference will be made to both nursing and midwifery - the budget setting issues pose the same pressures although midwifery has an All- Wales staffing tool: Birthrate Plus that must be adhered to. Community nursing teams have historical establishments and are being reviewed in four separate but related contexts: 1. The All-Wales Community Nursing Strategy; 2. Developing an acuity and dependency tool for community nursing in Wales; 3. Emerging locality teams; 4. Home enhanced care (the HECs model). It is recommended that no further changes are made to the Community Nursing (including District Nursing) until the locality model is clarified and the workload, including the acute to community shift is quantified in terms of workload, acuity and dependency. Data is being collated to benchmark staffing levels on an All Wales basis and this will be presented to the Nurse Directors and Chief Nursing Officer on the 25 th November In the meantime, comparative data has been obtained from Plymouth Hospital demonstrating higher ratios of nurses per bed. Data is being prepared from Salford Foundation Trust and from Wirral Hospitals. Health Visiting is a different field of nursing and on a separate part of the Nursing and Midwifery Register (part 3). There is both an English and Welsh review of Health Visiting at present; through the Labour Party Manifesto commitment there is a plan to increase the numbers of Health Visitors in Wales and these developments will be presented in a separate paper to the Workforce and Organisational Development Committee. 2. Situation Inability to achieve and sustain safe minimum nurse staffing levels and release staff for training has been a major challenge during 2010 and 2011, in particular for the adult general wards in the District General Hospitals (hereafter referred to as Acute Wards). Prior to, and after the mergers in North Wales, significant work has been undertaken and achieved to ensure that BCUHB has safe minimum nurse staffing levels in place. One of the key challenges for nursing in both Wales and the UK generally, is that there is no nationally agreed staffing tool, neither is there a legislative framework in which to determine staffing levels. This work is now underway in Wales at the request of the Directors of Nursing and has been commissioned by the Chief Nursing Officer (CNO) for Wales. The nurse staffing levels Jill Galvani Page 1 of 19

2 operating in Mid-Staffordshire have been under extensive scrutiny over the last few months as the CNO for England and the Nurse Director at the Trust have been questioned about optimal staffing levels during the enquiry (2011). The best available guidance at the time of the mergers was from the Royal College of Nursing (2006) and also the findings of the Welsh Audit Office (WAO) Ward Staffing Review* (main findings are summarised in section 5) undertaken in 2009 and published in The WAO review afforded benchmarks across Wales and within North Wales. The findings of this report have been presented to the Audit Committee and are at the end of the document as a point of reference. The Director of Nursing and Midwifery directed nurse staffing levels towards the following minimum standards for general wards: A skill-mix of a minimum of 65:35 registered nurse to Healthcare support worker; The Ward sister to be supernummary in line with RCN guidance (2009) and to deliver the WG strategy: Free to Lead; Free to Care (2008). The benefits of supernummary status to high standards of nursing care and of personnel management are attached at Appendix 3; Each ward to have a Housekeeper to deliver both the Free to Lead; Free to Care national strategy and to deliver on Cleaner Hospitals Strategy; Each ward to develop minimum staffing levels; in general these would be 7 staff on the early shift, 5 on the late shift and a minimum of three staff on at night; this modelling is referred to as the professional judgement model and may vary dependent on the speciality or case-mix of the ward; An up-lift of 26% to be applied to the nursing establishment to allow for an average of 4% sickness, and to allow for training and development (at this is detailed in Appendix 1 to explain how the 26% uplift figure is calculated. Throughout the time since the 2 mergers in North Wales, work has been underway to continually refine the nursing establishments against the 2006 RCN Guidance. Whilst doing this, in July 2010 the allocated cost improvement programme of 6% was apportioned to all nurse staffing lines. Once again, as is good practice, the Director of Nursing and Midwifery directed a further assessment of the impact of this on ward staffing establishments. The impact of the change in July 2010 meant that the Primary, Community and Specialist Medicine CPG (PCSM CPG) would need to be reduced by 252 WTE (10% of the nursing workforce) and 184 WTE within the Surgical and Dental (S & D CPG) nursing workforce. The August 2010 review was undertaken and included the community nursing establishments as these were found to be high and rich in skill mix during the WAO Review of During this review we achieved the following: All wards were allocated the 26% headroom, and an average skill mix ratio of 66:34 achieved in PCSM CPG and 69:31 achieved in S & D CPG although this average figure included the assessment units with higher skill mix ratios, and within the average, some wards remained under the RCN recommended 65:35 within both CPGs; Supernummary status was not achieved for any ward sisters and was not achievable within the budget; Housekeepers were already in place in Ysbyty Glan Clwyd; progress with introduction into Wrexham Maelor and Ysbyty Gwynedd (YG) has been limited; Revised rotas were introduced through the E-rostering system to maximise efficiency and minimise waste; Rotas were set using the professional judgement model. Jill Galvani Page 2 of 19

3 As a result of the August 2010 Review, nursing savings were realised through the elimination of inefficient rotas and the judicious use of temporary staffing. A further review of nurse staffing was undertaken in April 2011 following the publication of revised and updated RCN guidance in December The reasons for this review were three-fold: New guidance had been issued and we needed to test our position against it; in particular best practice ratios of one Registered Nurse to look after 6 (optimal) to 8 patients per shift to deliver minimal breaches in patient care delivery; Continued professional concern about the roll-over financial position; vacancy controls against budgets when the acute wards hadn t changed in terms of bed numbers and nurse staffing levels were average or below average to start with in 2009 (WAO), against a background of increased activity and productivity through improved length of stay, increased bed occupancy, increased day surgery rates, and evidence of increased acuity and dependency of patients; Evidence was emerging from the CNO (Wales) commissioned review of nurse staffing where a minimum of 1.03 WTE nurse per bed was required to deliver consistent nursing care (the figure in England is cited as 1.22 WTE and as high as 1.75 WTE (Hurst, 2011 in his work for BCUHB). We needed to test our position against this. It is important to understand what was different about the 2010 RCN guidance. The minimum requirements remained extant as listed above; Keith Hurst (referenced in the preceding paragraph and a UK expert on nurse staffing and patient outcomes) is undertaking specific dependency work with the Health Board. His work recommended a Nurse per Occupied Bed ratio (NPOB) of 1.75 and the emerging All-Wales work was demonstrating that North Wales had some of the lowest ratios and nursing staff numbers overall. The April 2011 review established that in the PCSM CPG, 5 wards do not meet the 1.03 nurse: bed ratio. Twenty-four wards do not have the ward sister as supernummary. Skill mix is slowly adjusting as turnover occurs but to get all wards to the minimum of 65:35 requires a substitution of Band 2 Healthcare support workers to staff nurses. Once the bed configuration has been achieved in S & D CPG, the nursing staffing will meet the standards set out in the RCN guidance. The costs of meeting these minimum standards for the acute wards in the PCSM CPG are million and can be achieved by consolidating nursing delivery within the CPG rather than allowing it to continue to be overstretched across too many areas, some of which are inefficient. A separate SBAR from the PCSM and S & D CPGs has been developed and discussed with the Executive Lead for PCSM where resources need to be realigned to meet minimum staffing requirements. 3. Background The Director of Nursing, Midwifery and Patient Services has a professional duty to ensure nurses and midwives are not placed in a situation whereby they are unable to discharge their responsibilities under the Nursing and Midwifery Council Code. It is good practice to involve the Board in setting nurse staffing levels; it is good practice to continually review nurse staffing levels as situations change for example complaints about nursing care or outbreaks of infection are indicators that nurse staffing levels should be reviewed. The impact of reduced resource allocation without changes to ward bed numbers is a situation where a review of nurse staffing numbers is required. Provision of safe minimum nursing and midwifery staffing levels is one of the areas within the BCUHB Nursing and Midwifery Quality Assurance Framework previously approved by the Quality & Safety Committee. A position report on the Assurance Framework will be on the December 2011 agenda of the Quality and Safety Committee. Jill Galvani Page 3 of 19

4 Safe minimum staffing levels allow the organisation to deliver safe, effective & quality care to patients & service users. Failure to achieve safe minimum safe staffing levels will: 1. Impact on BCUHB s ability to deliver safe effective care; 2. Fundamentals of Care will be compromised leading to breach of duty of care and risk of litigation; 3. Harm to BCUHB reputation, for example the Ombudsman s Casebook Report (April 2011) and the position of BCUHB with national reports such as those by the Older People s Commissioner (2011) and the Patients Association (2011) that make direct reference to setting safe nursing staffing levels. The impact of poor nursing staffing levels has received recent adverse media coverage such as Mid-Staffordshire and Basildon MHS Trusts with subsequent imposition of professional or statutory sanctions via the NMC and the Care Quality Commission (Health Inspectorate Wales equivalent) report published on 13 th October The following actions are directed by the Director of Nursing, Midwifery and Patient Services through the Assurance Framework: 1. The Associate Chiefs of Staff Nursing and Midwifery, supported by the Assistant Directors of Nursing develop and deliver a system of assurance that safe staffing levels are agreed and maintained. 2. An annual review of skill mix, dependency and acuity is undertaken with commitment to act on the outcomes of the review through workforce redesign. 3. A regular Birthrate Plus exercise is undertaken for the midwifery service with commitment to act on the outcomes of the review through workforce redesign. 4. Policies are in place to enable concerns to be raised to the Director of Nursing, Midwifery & Patient Services. 5. Incident reporting relating to nurse and midwifery staffing levels is collated on a monthly basis to detect potential problems and trends at an early stage. 6. The Director of Nursing, Midwifery & Patient Services will work with the Director of Finance to inform and influence resource allocation. 7. Concerns about nurse and midwifery staffing levels will be raised at the Board. Most importantly, inadequate nurse and midwifery staffing levels impact on service user experience leading to poor public image and a lack of confidence in the services BCUHB provides (Fundamentals of Care). Following the merger, evaluation of the E-Rostering position revealed significant variances in the number and length of shifts. This position has a resource implication, particularly in terms of the emergent 12 hour shift and overlap. Work is progressing well on this and is being reported to Finance and Performance Committee separately. Whilst the Health Board is regarded as being a national leader in delivering improved staff management through E-rostering, this project is a key strand for nursing and midwifery to demonstrate that it is as efficient as possible with the resources available to it. Historically, budgets in East and Central have been set at midpoint. The Director of Nursing, Midwifery & Patient Services view is that nurses and midwives budgets are rolled over at actual rather than mid-point as this puts nursing into an immediate overspend position at the beginning of the financial year against a backdrop of low staff turnover. If a decision to replace a member of staff is based on budget position, then Ward Sisters will not be in a position to replace staff in teams that are already at minimum staffing levels. If setting budgets at actual point is not possible, Jill Galvani Page 4 of 19

5 then the difference between funded and actual establishments should be made clear to inform whether or not a ward is in an overspend position when deciding to replace vacancies. The position with covering maternity leave remains unresolved and yields further staffing and budget pressures in nursing and midwifery, a mainly female staff group. Finally, one to one nursing to ensure patient safety is not accounted for in budget setting and would be part of the dependency / acuity work commissioned by the Strategic Nursing and Midwifery Committee. 4. Assessment Nursing has worked hard at delivering safe minimum staffing levels from existing resources and has made adjustments following the application of cost improvement plans or financial adjustments. The PCSM CPG needs to reduce its operational footprint to shift resources into the District Generals to achieve the recommended minimum standards. The community nursing (district nursing) budgets should not be re-aligned to meet acute care needs until the following strategic objectives are met: 1. The All-Wales Community Nursing Strategy recommendations are delivered within timescales; 2. The acuity and dependency tool for community nursing in Wales is implemented to determine the requirements of the district nursing service in North Wales; 3. The needs of the emerging locality teams are identified with plans to meet these needs; 4. The Home enhanced care (the HECs model) is delivered across North Wales. Any further resource reductions in nursing and midwifery staffing must be accompanied by a permanent reduction in either the number of beds or service. In reality this is not achievable as BCUHB needs to maintain the number of acute beds to support access for emergency and elective work until the locality model is implemented. 5. Recommendations The Director of Nursing, Midwifery and Patient Services recommends that: 1. Inherited and unaddressed problems and differences should be rectified during the 2012/13 budget setting process. In particular, lead nurses and midwives and their team leaders / ward sisters must fully participate in the budget setting process and vacancy control this year and beyond to enable accountability and responsibility for budgets and to set a firm framework for financial balance whilst delivering safe, effective, quality nursing and midwifery care to patients and service users (Fundamentals of Care in Appendix 4). In detail this will be: A minimum of 65:35 registered to healthcare support worker ratio; A minimum of 1.03 nurses per occupied bed; The Ward sister is supernummary; Each ward has a housekeeper. 2. The consequence of not addressing staffing levels during budget setting will result in permanent reduction of services provided by nurses and midwives. 3. A workable and affordable solution to covering maternity leave is agreed to sustain nursing establishments. 4. The Board supports the development and implementation of dependency and acuity scoring during 2011/12. Jill Galvani Page 5 of 19

6 5. The community nursing (district nursing) budgets should not be re-aligned to meet acute care needs until the strategic objectives set out in section 4 are met. *The Welsh Audit Office undertook a review of Ward Staffing in wards (including Community Hospitals), Critical Care and Paediatrics in 2009 prior to the merger of the NHS Trusts into the Health Board. The findings were issued to BCUHB in January 2010 and were presented to the Heads of Nursing, the Board of Directors and to Ward Sisters. The findings can be summarised as follows: The majority of wards are on or below the All-Wales average WTE levels and costs per bed; BCUHB is in the upper quartile for community hospital and critical care WTE per bed; Qualified to unqualified skill-mix is above average at 70:30 (average); Higher numbers of Band 3 posts in Central (probably housekeepers); Costs per WTE are slightly higher than the average (?high retention, low turnover); Spending is exceeding budget, particularly in Central ; Overall, wards operating at or below establishment; All areas had low use of temporary staff (agency eliminated in 08/09); Headroom or uplift varied from 16% to a reported 26%; Sickness levels were in the upper quartile; Levels of sickness in the West exceed that planned for; Numbers of nurse specialists varied from 75 WTE to 45 WTE. It is very important to note that the WAO data did not relate nurse staffing numbers to patient outcomes as in previous years (falls, pressure sores, medication errors or needle stick injuries). Patient dependency and acuity was not addressed. 5. References Hurst K (2002) Selecting and applying methods for estimating the size and mix of nursing teams London: Department of Health Setting Safe Nurse Staffing Levels London: RCN (2006) RCN Policy Unit (2006) Policy guidance; setting appropriate ward staffing levels in NHS acute trusts Breaking down barriers, Driving up Standards (RCN 2009). Guidance on Safe Nurse Staffing Levels in the UK (2010) London: RCN Jill Galvani Page 6 of 19

7 Appendix 1: Nursing Cover Budget/Headroom Requirements Appendix 1 Introduction It is practice to provide additional finance to establishment costs to allow for annual leave, sickness and study leave. The RCN (2006, 2010) recommends 25%; Welsh Assembly guidelines advocate 24%. Midwifery Units in Wales use the Birthrate Plus tool to identify establishment needs and Heads of Midwifery in Wales have agreed to 24% plus 1% to allow for statutory supervision. Locally in North Wales the additional cover budget is variable. In the East it ranges from 5% - 20%, in Central it is 22% and in the West it is 26%. Examples below give hours p.a. these additional percentages equate to: Table 1 Additional WTE allowance HOURS P.A. 18% % % 507 Rationale for additional cover based on 1 WTE where annual hours = 1950 The table below identifies needs in terms of additional headroom annually. Table 2 Registered Unregistered Annual leave (>10 yrs) % sickness *Mandatory Training (appendix i) Maternity/paternity/adoption leave NMC PREP requirements 11.7 **TOTAL (24.4%) (23.1%) ** The total hours in table 2 do not include additional field specific requirements, one off training requirements which may also be mandatory, or study leave requirements. Appendix ii shows in more detail rationale for recommended 26% headroom. Maternity Leave On examining maternity leave data from for nurses and midwives, this ranged from 1.97% to 2.94%. Data from shows an average maternity /paternity/adoption leave of 1.85% %. Adding an additional 2% to headroom would offer a conservative average. Mandatory Training The mandatory training totals above do not include one off training such as nutrition, dignity, tissue viability, aseptic techniques, continence care. In addition, nurses and midwives are required to provide mentorship for learners on a regular basis. This calculation does not include the initial minimum 5 days training (1.9%) required for this. In addition midwives have a statutory requirement to attend additional updates lasting 3 days annually requiring additional 1.1% headroom. Study Leave Jill Galvani Page 7 of 19

8 The changing requirements of health care, changing needs of patients and the need to modernise and re-profile healthcare posts means that there is a need for nurses and midwives to maintain and improve their practice to ensure evidence based care is delivered at all times. Maintaining registration requirements for registered nurses by the Nursing and Midwifery Council are that they demonstrate a minimum of 35 hours continuing professional development in the previous three year period (this equates to 0.6% p.a.). It should also be noted that many nurses are required to undertake further post registration education in relation to their role and service development. An example of this would be a nurse taking on advanced roles who is required to complete a Masters Level programme in Advanced Clinical Practice, and Clinical Nurse Specialists and Nurse Practitioners who are required to achieve degree level study in the area of their speciality. Most degree and Masters programme include at least 900 learning hours per academic year, of which many are undertaken out of working hours. However a proportion of which will be attendance at study sessions which is generally 10 days per module, 3 modules per year. Therefore for the proportion of nursing and midwifery staff undertaking further degree or masters level study in order to ensure world class care to patients this accounts for 11.5%. Currently Health Care Support workers are required to complete an QCF. This requires approximately 6 ½ - 8 days of learning (dependent on level) (2.5 3%) in the first year and then approximately 4 days per year of optional study sessions (1.5%). A recently introduced initiative to support HCSWs to a higher level requires ½ day per week over an academic year (7%). Managers evaluating this programme have reported improved practice, and increased confidence and knowledge. Therefore it is clear that whilst there is a need to provide additional cover for annual leave, sickness absence and mandatory training, there is also a need to support nurses and midwives to continually develop their practice, as a statutory requirement to adhere to the Nursing and Midwifery Council, as a requirement of their roles, and to enable evidence based practice and improved patient care. Whilst not all nurses and midwives will undertake study in addition to the mandatory training and CPD, it will be required for some nurses and midwives in order to maintain a high standard of service and care. Recommendation o That 26% headroom for nurses and midwives is agreed in the new organisation to ensure consistency across North Wales for nurses and midwives in terms of equity and for E- Rostering requirements. o An average maternity leave percentage is identified for nursing so this leave can be managed effectively. References RCN Policy Unit (2006) Policy guidance; setting appropriate ward staffing levels in NHS acute trusts Lynne Grundy August 2009 Updated November 2011 Jill Galvani Page 8 of 19

9 Calculations - registered nurses appendix ii hours p.a. % Comments Annual Leave % Sickness (target) % Mandatory training basic % NMC PREP % Average mat leave % TOTAL % one off training (not including mandatory min hrs fro mentors) 39.5* 2.00% % Additional field specific mandatory training requirements % of WTE This calculation is based on annual leave allowance for service greater than 10 years given the profile of our nursing staff All wales sickness absence target for BCUHB Basic mandatory training for all registered staff, average per year. Specific fields (e.g. mental health, midwifery are required to undergo mandatory training) Calculated on minimum requirement of 35 hours over 3 years Average BCU maternity/paternity /adoption leave = 1.85% % Relates to training which is required as a 'one off', frequently additional requirements are implemented (e.g. nutritional learning tool) hours p.a. Total Mental health mandatory training % 25.1% + 2% 'one off' % Midwives mandatory training % 25.6% + 2% 'one off' % Totals DO NOT include other CPD, e.g. Masters programmes, sisters development programmes, clinical education requirements appendix i Jill Galvani Page 9 of 19

10 Training time Reg Nurses Unreg nurses Training annual commitment (hrs) *average p.a. annual commitment (hrs) *average p.a. Blood transfusion Child Protection L COSHH Fire safety 1 1 Infection control 1 1 Infusion devices 4 manual handling 7 7 ILS 4 3 Prevention of violence 4 POVA one off commitment reg nurses one off commitment unreg nurses NEWS/RRAILS 1 5 MUST/nutrition e learning 3 3 Tissue viability 3 3 Continence 7 3 ANTT 1 ALERT 7 NVQ induction 7.5 cannulation 4 IV additives 7 New technologies 2 1 All Nurse/midwife mentors 2 Dignity training 7.5 TOTAL All Nurse/midwife mentors Additional training required Midwives K2 CTG training 8 Child Protection L Breast feeding BFI 1.5 comments L3 = 6hrs, L4 = 2 days 14hrs initial training mandatory NMC requirement mandatory NMC requirement SoM training* (inc. mandatory training updates 14.5 hrs) days initial training Domestic abuse 1 1 day initial training TOTAL ADDITIONAL Mental health Breakaway 5 5 Suicide prevention 1 1 Mental Health Act 1 1 CPA/Risk management 5 HoNOS 1 POVA L3 2 TOTAL ADDITIONAL 15 7 Generic total 28.5 Mental Health (Reg) 43.5 Midwives Jill Galvani Page 10 of 19

11 Appendix 2: Nurses and Midwives identified core training Fire safety Manual handling Infection prevention Blood transfusion Infusion device training Resuscitation training *Safeguarding Children training *POVA Violence and aggression In addition, nurses and midwives must receive adequate training and support which is likely to be ward based in: Early warning score and action Asepsis New technologies (for example beds, infusion pumps etc) *at level appropriate to work requirements In addition: Mental Health Breakaway training Suicide prevention Mental Health Act CPA / Risk Management Health of Nation Outcome Scores (HoNOS) POVA Level 3 (all qualified staff) Midwifery CTG assessment training package CTG updating Child Protection L3 Breast feeding BFI Midwifery 3 day training course Domestic abuse *includes emergency drills, neonatal resuscitation, antenatal screening, epidural update, drug and alcohol misuse. Jill Galvani Page 11 of 19

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14 Appendix 3: Ward Sister/Charge Nurse; Supernumerary status It is clear that the demands on Ward Sisters/Charge Nurses are increasing; they are seen as pivotal to ensuing high standards of quality care and are responsible for managing large teams of staff within a set budget. Following the publication and implementation of Free to Lead, Free to Care the status and responsibility of Ward Sisters/Charge Nurses has been further consolidated. The challenge is how to lead and manage their teams effectively, deliver an excellent service within resources, ensuring care standards are high, and manage related budgets. The Director of Nursing, Midwifery and Patient Services advises that Wards Sisters/Charge Nurses should be supernumerary in line with the RCN recommendation that ward sisters/charge nurses are supervisory to shifts. What is supernumerary status? For the purpose of clarifying supernumerary status for Ward sisters/charge Nurses in the former North Wales Trust, this was discussed with the two current cohorts of RCN CLP participants and the following criteria were identified: o Additional to clinical staffing requirements. o Named on rota but NOT taking/allocated clinical workload, though still available to undertake clinical work. o Work 5 days Monday Friday, overseeing care delivery, ensuring helicopter view of clinical environment. o Work one late shift per week. o In uniform, visible and on the shop floor supporting the team, ensuring standards are maintained, helping with difficult cases, teaching, coaching and mentoring students and staff. o Available and accessible to all staff, visitors and patients. o Available for ward rounds. o Has 24 hour, 7 days per week responsibility for the ward. o On general ward areas one WTE Band 6 to deputise, and ward sister/charge nurse responsibility to develop Band 6 role and individual. This criteria is in line with RCN recommendations within Breaking Down Barriers, Driving up Standards (RCN 2009) which states: The RCN recommends that all ward sisters become supervisory to shifts so that ward sisters can: o Fulfil their ward leadership responsibilities; o Supervise clinical care; oversee and maintain nursing care standards; o Teach clinical practice and procedures; o Role model good professional practice and behaviours; o Oversee the ward environment; assume high visibility as the nurse leader of the ward. Jill Galvani Page 14 of 19

15 Appendix 4: Fundamentals of Care STANDARD 1 COMMUNICATION AND INFORMATION Principle: You will receive full information about your care in a language and manner sensitive to your needs. STANDARD 2 RESPECTING PEOPLE Principle: Your human rights dignity, privacy and informed choice will be protected at all times, and the care provided will take account of your individual needs, abilities and wishes. STANDARD 3 ENSURING SAFETY Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and were possible, reduced or prevented. STANDARD 4 PROMOTING INDEPENDENCE Principle: The care you receive will respect your choices in making the most of your ability and desire to care for yourself. STANDARD 5 RELATIONSHIPS Principle: You will be encouraged to maintain your involvement with family friends and to develop relationships with others according to your wishes STANDARD 6 SLEEP, REST AND ACTIVITY Principle: Consideration will be given to your environment and comfort so you may rest and sleep STANDARD 7 ENSURING COMFORT ALLEVIATING PAIN Principle: You will be helped to be as comfortable and pain free as your condition and circumstances allow. STANDARD 8 PERSONAL CARE AND HYGIENE, APPREARANCE AND FOOT CARE Principle: You will be supported to be as independent as possible in taking care of your personal hygiene, appearance and feet. STANDARD 9 EATING AND DRINKING Principle: You will be offered a choice of food and drink that meets your nutritional and personal requirements and provided with any assistance that you need to eat and drink STANDARD 10 ORAL HEALTH AND HYGIENE Principle: You will be supported to maintain a healthy, comfortable mouth and pain free teeth and gums, enabling you to eat well and prevent related problems. STANDARD 11 TOILET NEEDS Principle: Appropriate, discreet and prompt assistance will be provided as necessary taking into account your specific needs and privacy. STANDARD 12 PREVENTING PRESSURE SORES/ PRESSURE ULCERS Principle: You will be helped to look after your skin and every effort will be made to prevent you from developing pressure sores. Jill Galvani Page 15 of 19

16 Appendix 5 (Comparative Plymouth Data): Jill Galvani Page 16 of 19

17 Appendix 6 (Comparative BCUHB Medical Wards Data): Current position from AUKUK 2010 Planned position 2012 / 2013 following budget setting Ward Speciality Beds Current estab Ratio per bed Beds Var beds Prop estab Var estab Ratio RN:HCA Ratio per bed Hebog Renal Cunliffe Renal Ward 10 Renal/endo Glaslyn COTE/endo Mason Endocrinoogy Moelwyn Respiratory Evington Respiratory Ward 12 Respiratory Glyder Cardiology Ward 9 Cardiology ACU Cardiology CCU CCU CCU CCU CCU CCU Bersham Stroke Prysor Stroke Ward 14 Stroke AMU AMU AMU AMU Tryfan AMU Ward 11 Gastro Gogarth Gastro Ward 1 COTE Morris CoE Ward 2 CoE Erddig CoE Movement Jill Galvani Page 17 of 19

18 Appendix 7 (Results from Welsh Audit Office 2009): Jill Galvani Page 18 of 19

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