SOMERSET PARTNERSHIP NHS FOUNDATION TRUST SIX MONTHLY REVIEW OF STAFFING ESTABLISHMENTS TIME TO TALK, TIME TO LISTEN, TIME TO CARE

Transcription

1 SOMERSET PARTNERSHIP NHS FOUNDATION TRUST SIX MONTHLY REVIEW OF STAFFING ESTABLISHMENTS TIME TO TALK, TIME TO LISTEN, TIME TO CARE Report to the Trust Board 24 November 2015 Sponsoring Director: Author: Purpose of the report: Key Issues and Recommendations: Director of Nursing and Patient Safety. Director of Nursing and Patient Safety. Chief Operating Officer. Report on progress with meeting recommended staffing levels on inpatient wards. In May 2014 the Trust Board approved new staffing establishments which were bespoke for each ward and supported by significant additional investment to recruit to additional registered nurse posts. Good progress has been made with sixteen out of 24 wards regularly achieving fill rates in excess of 80% of the recommended staffing levels. Following recent correspondence from Monitor and NHS England the Trust has looked at opportunities to make the wards more efficient. This includes a renewed focus on rostering practice with monitoring of key performance indicators; continuing to proactively manage sickness absence with a focus on the 16 wards who have a sickness absence level higher than 3.5%; a review of preceptorship supervisory practice; the development of a protocol for enhanced observations in community hospitals; the facility for Ward Managers to use 12 hour shifts subject to achieving core staffing levels at all times; more robust monitoring of the reason for bank/agency requests; November 2015 Public Board - 1 -

2 a detailed review of the bank and agency functions within the Trust. It is recommended that the funded establishments of 16 wards are amended. Actions required by the Board The Trust Board is asked to approve the recommendations and revised ward establishments. November 2015 Public Board - 2 -

3 SIX MONTHLY REVIEW OF STAFFING ESTABLISHMENTS TIME TO TALK, TIME TO LISTEN, TIME TO CARE 1. PURPOSE 1.1 The purpose of this report is to update the Trust Board on progress made in meeting the recommended standards for safer staffing on all of our inpatient wards, to recommend a number of changes to the current establishments and supporting actions. 2. BACKGROUND 2.1 In November 2013, NHS England published: How to Ensure The Right People, With The Right Skills, Are In The Right Place At The Right Time - A Guide to Nursing, Midwifery and Care Staffing Capacity and Capability. In this guide, endorsed by the National Quality Board (NQB), NHS England set out the expectations of commissioners and providers to optimise nursing, midwifery and care staffing capacity and capability so that they can deliver high quality care and the best possible outcomes for their patients. 2.2 The NQB guidance was issued in response to the Francis report into the failings at Mid Staffs where inadequate staffing levels on the wards were found to significantly contribute to the poor care received by patients at the Trust. The NQB report confirmed that NHS England expected all organisations to be meeting these expectations currently, or taking active steps to ensure they do so in the very near future. 2.3 The report identified ten new Trust Board responsibilities for ensuring that Safer Staffing was in place including taking full and collective responsibility for nursing, midwifery and care staffing capacity and capability. These are summarised in Appendix One. 2.4 In order to achieve this the Trust Board is required to agree staffing establishments for each ward; to consider the impact of wider initiatives such as the cost improvement plans; to monitor staffing capacity and capability through regular reports on the actual staff on duty on a shift by shift basis, versus planned staffing levels; to examine trends in the context of key quality and outcome measures; and to review recruitment, training, skills, experience and management of nurses. 2.5 Trust boards are asked to give authority to the Director of Nursing to lead this process and report this at Board level with an annual formal review at a public board meeting and a minimum of six monthly November 2015 Public Board - 3 -

4 reviews in between. It is recognised however that the Director of Nursing will work closely with the Medical Director, Chief Operating Officer, Director of HR and Director of Finance and Performance given the interdependencies of functions. 2.6 On 13 October 2015 NHS England, Monitor, Trust Development Authority, NICE and Care Quality Commission (CQC) jointly wrote to all trusts in recognition that a recent series of communications could be seen as contradictory. The letter served to remind all Trust boards that they need to be able to demonstrate that they are able to ensure safe, quality care for patients and that they are making the best use of resource. The letter re-iterated that the responsibility for both safe staffing and efficiency rests with provider boards. 2.7 Trusts were also reminded of the importance of the professional judgement made by ward sisters/charge nurses together with the responsibility of Trusts to take into account patient acuity and dependency, time of day and local factors such as the line of sight of patients. There was also a reminder to look at staffing in a flexible way focussing on the quality of care, patient safety and efficiency rather than purely numbers and ratios. Trust Board approval of establishments May 2014 to date 2.8 On 27 May 2014, the Somerset Partnership Foundation Trust Board received and approved the ward establishment for each of the community hospitals and mental health wards and agreed additional investment to support the recruitment of additional registered nurses and health care assistants. The Trust has subsequently published the monthly performance for each ward for both recommended staffing levels and actual - on the public website, and regularly considers trends, reasons for any gaps and actions taken to address these at the public Trust board meeting. 2.9 In October 2014 a six monthly review was undertaken with three amendments to the staffing establishments approved by the Trust Board. This included : moving HCA mid shifts in community hospitals back into early shifts as the ward sisters felt that they were hard to staff and not an effective use of time; agreement to staff West Mendip as one ward rather than two; approval of the establishment for Wessex House prior to reopening. November 2015 Public Board - 4 -

5 2.10 In May 2015 the first annual review of staffing levels was completed and the report presented to the Trust Board. The Trust Board agreed three specific changes to the establishments: increase health care assistants by one per shift, for ward Rydon Ward 1and 2; confirm the leadership structure on Pyrland Ward; strengthen ward leadership by creating 3 additional community hospital junior sister posts at Frome, Bridgwater and South Petherton Hospitals. 3. BALANCING QUALITY, SAFETY AND EFFICIENCY 3.1 Staffing levels impact upon the ability of nursing staff to provide high quality care (NHS England Nov 2014) and nationally there is recognition that care is compromised if the threshold for the number of registered nurses per patient drops below one nurse per eight patients. 3.2 The Care Quality Commission report The state of health care and adult social care in England 2014/15 was published in October 2015.This makes reference to the Francis report (2013) which showed that inadequate staffing leads to poor quality care. In the report they specifically raised concerns that from September 2009 to March 2015 there was a 15% drop in the total numbers of inpatient psychiatric nurses- the equivalent of 4,000 RMNs. Across all services CQC have inspected nationally, services were most likely to receive an inadequate rating for safety, and staffing is a core factor in their assessment. 3.3 Trusts rated as good and outstanding by the CQC had rotas that were well planned with less reliance on agency staff.there were still times when the staffing levels or the skill mix fell below the level that trusts said they needed to properly care for people. When this happened the CQC inspection report showed that risks to patient safety grew, and there were often more medication incidents, even in Trusts we rated good and outstanding. They found that in trusts rated good/outstanding they prioritised measures to meet patient demands. 3.4 In trusts rated as inadequate by CQC the number of staff, skill mix and level of experience varied considerably, but generally numbers fell significantly below the level Trusts said they needed. This was especially the case during the night and at weekends (p.44). 3.5 Numerous studies have also demonstrated a statistical association between increased registered nurse levels and lower odds of hospital November 2015 Public Board - 5 -

6 related mortality and adverse events such as infections, falls and pressure ulcers (Kane, Shamliyan, Mueller, Duval and Wilt). 3.6 It is however important that we go beyond the numbers and look at the activities undertaken, and by whom, in order to ensure that as much of the valuable registered professional time as possible is spent providing direct patient care. All wards have undertaken a review of care contact time as part of this review of the ward establishments. Factors such as the amount of administrative support available on the ward, documentation requirements and the use of technology have all been found to affect the amount of direct patient time for each ward. Work needs to continue to ensure that wards are organised as efficiently as possible in order to release time for direct patient care. Implementing lessons from the inpatient ward Productive Series and involvement in the IP2 Releasing Time to Care projects will continue to be prioritised to support all wards to achieve this. 3.7 Work has already started to develop assistant practitioner roles with the Trust supporting four cohorts of staff to undertake training at Foundation Degree level with an initial focus on District Nursing, School Nursing, and Stroke Care. Their use in an inpatient setting for community and mental health wards is nationally not as advanced, however this is currently under review. We will monitor this progress closely but will also need to move ahead to develop our own assessment of the feasibility of introducing assistant practitioners into inpatient settings. Nationally discussions are also progressing with regards to developing an associate nurse with a shortened pathway from foundation degree to registered nurse. 3.8 There is also recognition that it is not just nursing and health care assistant levels which needs to be evaluated when considering the appropriate staffing levels on a ward. The contribution of Medics and Allied Health Professionals to the treatment and recovery of patients needs to also be considered. Utilising the National Mental Health Toolkit will further support this approach for mental health wards and there are new opportunities with the redevelopment of the Integrated Rehabilitation Teams (previously ILT) to further integrate our approach to staffing. Work has already started in key areas such as stroke and progress will be reported to the Trust board. 3.9 In terms of outcomes, the enhanced registered nurse and HCA establishments have been universally welcomed by all wards. This is particularly important for community hospitals who, prior to May 2014 had the lowest level of registered nurse to patient ratio of any primary care trust in the national benchmarking exercise (Audit Commission 2009). Whilst welcoming the additional resource, many wards do however note the increased bureaucracy associated with the mandated daily reporting and the perceived lack of flexibility on a shift by shift basis. This has been partially addressed through the November 2015 Public Board - 6 -

7 implementation of daily validation of the E roster and the reenforcement of professional judgement on a shift by shift basis. Following a validation exercise it is hoped that daily reporting of safer staffing performance will cease in December with information being pulled directly from the E-roster In terms of improved quality outcomes, since May 2014 the wards have seen a continued decline in patient falls and harm caused by falls, in the number of pressure ulcers, in the use of restraint and in the number of absence without leave. Each of these is recognised as a nurse sensitive indicator i.e. there is a correlation between the hours of registered nurse time and patient outcomes Since May 2015 the Trust has seen an overall improvement in fill rates for both day and night shifts whilst recognising that there have been periods when this has been challenging. The trend is outlined in the table below. November 2015 Public Board - 7 -

8 4. FACTORS INFLUENCING SAFE STAFFING LEVELS 4.1 In spite of pressure from various national bodies, NHS England and the National Quality Board have consistently shied away from setting minimum staffing levels fearing that Trusts will use these levels to set rigid staffing levels for each ward. 4.2 In line with national guidance the Trust approved individual, bespoke establishments for each ward. It is however important to remember that these are based on the assumption that the ward is full and the patients have average care - needs. 4.3 When either the bed occupancy or the dependency and acuity of patient s changes - the requirement for staffing will either increase or decrease. The role of the ward sister/charge nurse to use their professional knowledge and experience to balance these particular demands cannot be underestimated. We will highlight our continued expectation that staffing levels are flexed effectively in line with bed occupancy and patient dependency and acuity, and will support our nursing and operational managers to do so collaboratively. Dependency and Acuity 4.4 The drive to provide care closer to home, avoid admissions and to manage winter pressures means that wherever possible patients are discharged straight home from acute Trusts rather than being admitted to community hospitals. This means that patients are being transferred to community hospitals earlier in the pathway and the dependency and acuity appears to be increasing. 4.5 There is also recognition that there are increasing numbers of elderly patients with complex co-morbidities, including dementia, and that increasingly these patients are cared for in community hospitals. This has led to an increase in requests for extra resource to special patients at risk of wandering or falls. It is recommended that further work is completed to standardise and adopt best practice in specialing patients requiring enhanced observations in community hospitals. 4.6 The Trust does not monitor the dependency and acuity of patients on each ward and is therefore not able to systematically match the care needs of patients to care hours provided or required, or to develop trend data to support the establishment reviews. It is therefore recommended that the Trust prioritises the implementation of the Safer Care Module of E roster in community hospitals in order to establish a baseline and ongoing monitoring. 4.7 In mental health wards, the dependency and acuity of patients is often linked to the number of patients on enhanced observations. Nationally it is recognised that this proxy measure is not always accurate and November 2015 Public Board - 8 -

9 additional dependency tools have been identified as part of the new National Mental Health Safer Staffing Toolkit. The Trust has secured the national lead Keith Hurst to undertake a workshop with three pilot mental health wards in December. This will include the use of dependency tools. Bed Occupancy 4.8 The individual ward establishments are also based on caring for full wards of patients when in reality this may be very different. In October the cumulative rate of bed occupancy for all community hospitals was 89% with Dene Barton having the highest bed occupancy at 95.6% and Wincanton the lowest at 83%. This rate has been consistent since March this year. 4.9 For mental health wards the cumulative bed occupancy rate was 88.2% which has decreased from 90.5%. This ranges from 95.4% on Rowan ward to 71% at Wessex House. Other factors 4.10 There are a number of other local factors which influence the core staffing levels in each of the wards and these are taken into account when developing bespoke establishments for each ward This includes the visibility of patients (ward layout and number of single rooms), the demand for patient care at certain times of the day and the availability of medical cover. For example where there are large numbers of single rooms, and minimal access to medical support, it is recommended that a higher establishment of staff is rostered at peak times. This is the case for Minehead community hospital. 5. ACTIONS TO OPTIMISE EFFICIENCY 5.1 In June 2015 Lord Carter released his interim report Efficiency Review of Operational Productivity. This identified a number of key actions for acute Trusts many of which are equally applicable to Somerset Partnership. This included the importance of effective rostering of staff onto shifts and managing sickness absence as well as the introduction of Agency Rules in September E Rostering 5.2 The Trust implemented e-rostering across all inpatient wards over the winter of 2014/15 and supported this with the development and approval of a new Rostering Policy in June The policy outlines a set of principles for effective rostering including a series of key performance indicators. November 2015 Public Board - 9 -

10 5.3 A review of E-rostering and discussions with ward managers indicates that there is further work to be completed to ensure that all E rosters are completed in line with the E Roster principles. It is recognised that this may require the ward sister to have difficult discussions with team members to ensure that only the allocated number of staff are on leave at any one time, and that the difficult to fill and often unpopular shifts are rostered first. 5.4 Accountability for effective rostering sits with the ward sister/charge nurse and each has been required to review the process on their ward to ensure that it is as efficient as possible. A process of daily validation of the E roster was implemented in October 2015.It is recommended that benchmarking activity is conducted to ensure that the Rostering Principles and KPI s detailed within the Rostering Policy are sufficiently robust and that performance against the KPI s are monitored monthly and reported at ward and divisional level at the monthly operational directorate meeting. Flexible Working 5.5 In the hospitals currently under review nationally, Lord Carter has identified that retaining flexibility when rostering is a key indicator of success. A key action for Trusts under review has been for wards to review all requests for flexible working and to ensure that these are regularly reviewed in line with Trust policy ensuring that the needs of the ward remain the key factor when considering all requests for flexible working. 5.6 It is recommended that the Trust conducts a similar review and that these reviews continue annually at team and divisional level. Shift Patterns 5.7 In June 2014, the Trust Board approved the full adoption of 7.5 hour shifts as the shift of choice taking into account the evidence that suggested that nurses who work shifts of 12 hours or longer are more likely to experience emotional exhaustion, reduced job satisfaction with poorer outcomes for patients. At that time there was eighteen RMNs undertaking twelve hour shifts out of 377 wte registered nurses, and less than ten staff in community hospitals on flexible working patterns to support childcare or caring responsibilities some of which may involve long shifts. 5.8 The 2014 international research by the National Institute for Health Research Collaboration for Leadership (CLAHRC) at the University of Southampton surveyed 31,627 nurses across 12 countries. They found that nurses who work longer shifts and more overtime are more likely to rate the standard of care delivered on their ward as poor, give a negative rating of their hospitals safety and omit necessary patient care. The study also confirmed that the single biggest impact on patient outcomes was staff consistently working in excess of their November 2015 Public Board

11 contracted hours, regardless of shift length and suggested that further research was necessary to determine if there is a difference in outcome between those choosing to work 12 hour shifts and those required to do so, as well as identifying the manner in which any 12 hour shift pattern is introduced i.e. what checks and balances are put in place to protect the health and safety of staff and patient outcomes. 5.9 The Health and Safety Executive has undertaken a number of studies into the incidence of accidents and their association to the length of shift worked. In the first 8 to 9 hours the accident risk is constant, but deteriorates after this. Stimpfel (2011, 13) also highlights the worsening of patient care when staff work a 12 hour shift There do continue to be a small but consistent number of staff who would prefer to work a twelve hour shift in the Trust often due to minimising travel time or childcare responsibilities. In addition there is a number of staff who are working in excess of 12 hours principally because they continue to work to cover immediate gaps in the rota. We also have anecdotal evidence from managers that some staff have left the Trust to take up the opportunity of working 12 hour shifts in other organisations Conversely the Trust decision not to adopt 12 hour shifts is likely to be a positive factor for attracting staff to work for the Trust who don t want to work long shifts. This was reinforced by a recent survey of newly qualified staff who stated that the absence of twelve hour shifts was the second highest factor when choosing to work at the Trust Attracting and retaining staff is a key element of the Trust recruitment and retention strategy, and the ability for managers to offer 12 hour shifts as part of a blended approach to employment could be beneficial. It is therefore recommended that the Trust support the adoption of 12 hour shifts where this is in line with personal preference and can be accommodated safely and cost effectively from an operational perspective. The facility to use 12 hour shifts by Ward Managers is obviously subject to them achieving core staffing levels at all times. However, the Trust needs to balance the adoption of this revised approach with patient safety concerns. It is therefore recommended in parallel with the above that all inpatient staff are surveyed to establish how any changes might best be accommodated and what checks and balances might need to be factored into any future approach. This would be with a view to accommodating current (and any future) staff wanting to work long shifts within a structured blended programme of shifts which meet their preference, where this can be accommodated safely and patients can be protected from harm. Likewise the Trust could legitimately actively promote the standard 7.5 hours shift patterns through its recruitment programme. It is recommended that the Director of Workforce and Organisational Development conducts this review November 2015 Public Board

12 Sickness Absence 5.13 The Trust has allowed for 4% sickness absence within the establishment headroom for all wards. Where any ward exceeds this level, they will not have enough staff within their establishment to cover all of the shifts without using additional temporary staffing In September 2015, thirteen of the wards have sickness levels in excess of the 4% allowance with Ash, Dene Barton, Williton and South Petherton having levels in excess of 8%. This is likely to drive increased costs as ward sisters assess whether they need to cover vacant shifts. A summary can be found in Appendix Two The age profile of the nursing workforce nationally shows that 29% of nurses are aged over 50 years of age. For the whole Trust - 56% of all staff are aged over 46 years of age, and as the largest occupational group, it is likely that this profile is also reflected in the nursing workforce. Higher levels of long term sickness can be associated with an ageing workforce The Trust recently approved a new sickness management policy. HR business partners are now working closely with ward sisters to agree management plans with individual members of staff on long term sickness and each ward has identified effective sickness management as a priority in their financial recovery plans. Preceptorship 5.17 Part of the Trusts recruitment and retention plan is to recruit as many newly qualified nurses as possible and to support the wards to appoint them. These nurses are called Preceptees. It is recognised best practice to provide high levels of support to these staff in terms of a preceptorship programme and the Trust has a small team whose role it is to support preceptees whilst on the programme The Trust currently has12 preceptees working in community hospital wards and 11 working in mental health wards the full list can be seen in Appendix Three The Trusts Preceptorship policy supports newly qualified staff by ensuring that they work in a supernumerary capacity until they feel confident and competent. The length of time is not determined and is left to each individual ward in community hospitals to agree what is appropriate. For mental health wards there is an agreement that preceptees will work in a supernumerary capacity for the first two weeks and should not take charge of the ward for the first twelve months however this is not detailed within the policy For wards who take a larger number of preceptees like Frome and West Mendip some allowance needs to be made for covering registered nurse time to support preceptes and the associated cost. It November 2015 Public Board

13 is however recommended that the Trust policy is reviewed and standardised to ensure that a balanced approach is taken towards supporting new staff and efficiently running the ward, outlining in particular the length of time preceptees will operate in a supernumerary capacity. Agency Rules 5.21 During the twelve month period up to 31August 2015, 13 trusts within the NHS Peninsular Purchasing and Supply Alliance spent approximately 47 million on agency nursing with much of the expenditure on non-framework agency providers. Monitor and the TDA recognise that there will always be a requirement for trusts to use temporary staff however it is recognised that the current level of spend on agency staffing is unsustainable. The new Agency Rules require all trusts to only use agencies on the approved framework agreement. The Trust is still waiting for feedback following its request for agencies to go onto the approved framework All trusts have also been set an annual ceiling for total agency expenditure which is a percentage of total expenditure on nursing. For Somerset Partnership, Monitor has set a target of 5%. Progress against this is monitored on a weekly basis by the executive team and will now be formally reported to the Trust Board each month. Bank/Agency Office 5.23 A robust authorisation process for all bank and agency requests is now in place with a requirement for all requests to be authorised and handled by the Staff Bank in hours, and the on call manager/director - out of hours. The new agency rules require all Trusts to utilise onframework agencies and within this, to prioritise cheaper agencies It is essential that the Trust has responsive and effective arrangements in place from the Staff Bank and enough capacity to meet demand therefore reducing the reliance on agencies. Feedback from ward sisters/managers indicates that the current arrangements for securing bank staff are not optimal and this is resulting in higher than expected unfilled shifts being allocated to agencies It is recommended that an urgent review is conducted of the Trust s current bank service to determine if there is sufficient capacity to support the demand at both a managerial and operational level. The local relationship between wards and bank staff is important, and therefore an option to decentralise the booking function should also be considered. The scope of rewards and enhancements as well as the support and learning available to bank staff is important to attract and retain bank staff and should be assessed along with consideration given to whether better synergy could be derived from co-locating the bank/agency and E-roster teams which currently sit in separate November 2015 Public Board

14 directorates. It is recommended that the Director of Workforce and Organisational Development conducts this review The key driver for wards requesting temporary staff relates to either one or a combination of the following : increase in dependency/acuity of patients; covering sickness absence; covering vacancies; covering preceptors It is important that the Trust understands what is driving the use of bank/agency staff for each ward in order that the appropriate modification is adopted. For ongoing issues with dependency/acuity this may mean that the funded establishment needs to be amended. Currently the Trust is not systematically reviewing and monitoring the drivers for bank and agency spend and it is recommended that this commences as a matter of priority. Recruitment 5.28 The recruitment of registered nurses remains the main factor in the ability of the Trust to meet the agreed recommended establishment levels. The number of vacancies for both community hospitals and mental health wards has remained broadly consistent with around 34 wte vacancies in community hospitals and 30 wte vacancies in mental health wards The Trust Board has recently approved a recruitment and retention plan which included overseas recruitment. The Trust has commissioned Search Recruitment to act on its behalf in Spain and ten general nurses have been recruited and are due to start with the Trust between the end of November 2015 and early January An additional eight overseas nurses are due to be interviewed by the end of November with further overseas recruitment planned Recruitment to mental health nurse vacancies remains more challenging. The Director of Workforce and Organisational Development has recommended that the Trusts Recruitment and Retention Plan is reviewed to ensure that sufficient focus is devoted to retention and that recruitment activity is sufficiently robust and creative to provide the Trust with a competitive advantage. November 2015 Public Board

15 Ward Sister/Charge Nurse Supervisory Status 5.31 Of all aspects of care that the CQC look at, they state the quality of leadership most closely correlates with the overall quality of a service (The state of health care and adult social care in England 2014/15 CQC).Senior nurses play a crucial role in the care and treatment of patients and are often called upon to make important and critical clinical judgements and decisions and support junior and less experienced staff. An absence of ward leadership and time to lead can often lead to delayed decision making and/or risk adverse behaviours by junior staff The importance of good ward leadership has been acknowledged for some time. In 2010 the national standard as detailed in the Guidance on Safe Nurse Staffing Levels in the UK was clear that ward sisters/ward managers should be 100% supervisory and not included in the shift roster. This recognises the value of good leadership and the measurable improvement in outcomes for patients and staff when this is in place In recent months NHS England, Monitor and CQC have all actively promoted the importance of professional judgement when evaluating staffing levels on inpatient wards. This paper has also highlighted the important role that ward leaders play in terms of ensuring effective rostering, proactively managing sickness absence, supporting newly qualified staff and additional pre reg students on placement and promoting their wards for local recruitment campaigns. It is acknowledged that this takes dedicated time which cannot be easily released if ward sisters/charge nurses are working clinically with patients All wards sisters/charge nurses in community hospitals wards currently have two days as supernumerary and in mental health wards the majority have two days with some wards more. In May 2014 the Trust Board agreed that consideration would be given to increase the number of supervisory days in May 2015 to a minimum of three days per week (see section 6.24) In May 2015, the Trust Board reviewed this and committed to increasing the supervisory status for all ward sisters/charge nurses from April 2016.Further work will be undertaken with each ward to identify opportunities to increase the supervisory status of all wards from April November 2015 Public Board

16 6. PROCESS FOR REVIEWING WARD ESTABLISHMENTS 6.1 In line with the initial development of ward establishments and each of the two subsequent reviews, this six monthly review has been completed in partnership with front line ward sisters/charge nurses, Heads of Division and the Heads of Nursing. For each ward, key issues were identified by the ward sister/manager including direct care time, clinical care indicators, risks, recruitment to vacancies, the sickness level and use of temporary staffing. Detailed reports for each ward are available. 6.2 Further discussions were held at community and mental health best practice groups and all findings were reviewed by the Trusts Managing the Nurse Resource meeting. Each ward was also required to review their expenditure and specific efficiency targets and to develop a financial recovery plan which was submitted to the Chief Operating Officer. 6.3 Final stage collaborative work was undertaken utilising the individual ward feedback and the recovery plans at meetings involving individual ward sisters/managers, senior operational managers and senior members of the Nursing and Patient Safety Directorate. 6.4 Creative opportunities to optimise the utilisation of each ward staffing resource have been identified and agreed with each ward and these include the increased use of twilight and mid shifts to cover busy times of the day. These have been developed on the principle that the overall budget for each ward will remain, that all actions to optimise efficiencies at ward level will be adopted and that ward sisters/managers will continue to use their professional judgment to determine staffing levels on a shift by shift basis. 6.5 The key changes to each ward establishment have been co produced with the ward sister/manager, the Head of Division and the Heads of Nursing and have been signed off by both the Director of Nursing and Patient Safety and the Chief Operating Officer. 7. COMMUNITY HOSPITALS 7.1 By October 2015 eight of the 13 community hospital wards were regularly meeting 80% or above of the recommended staffing levels which is the best performance to date. 7.2 Ward sisters report that recruitment to vacancies remains their most significant challenge and there has been a significant increase in the amount of agency staff used in the last six months. November 2015 Public Board

17 7.3 Staff report that they are using the bank office but there is increasing levels of frustration in what they perceive to be delays in allocation of shifts to bank staff leading to additional short notice use of agency staff. 7.4 Ward sisters report an increase in patient dependency particularly at Dene Barton and Bridgwater hospitals and a concerning lack of acknowledgement from acute Trust regarding the lack of immediate access to medical support. There is a good level of support from all wards for the implementation of the Safer Care dependency tool as this will facilitate a systematic evaluation and tracking of patient dependency on each ward. 7.5 Seven day admissions and late transfers of patients from acute trusts has identified a need to maintain staffing levels on the late shift and through to night duty and over the seven day period. 7.6 All wards report an increase in the number of patients with dementia. There are also additional requirements following the recent Care Act to include capacity, consent and DOLs. This has necessitated a change of practice supported by additional training and improved access to mental health advice. 7.7 None of the wards report that the establishments are unsafe but all recognise that there is a continued requirement to use their professional judgement on a daily basis to ensure that the appropriate levels of staff are available to meet the care needs for the number of patients on the ward. 7.8 All ward sisters have an allocation of supervisory hours but many are unable to take this time due to gaps in rostering. The majority of ward sisters state that the current allocation of supervisory time is inadequate to meet the leadership requirements for their role. Proposed changes to ward establishments Wincanton 7.9 Wincanton currently delivers inpatient care over two small wards of eleven and seven beds, each operating as a single sex ward. This is highly inefficient in terms of cost per bed and potentially fragments care as staff try to cover each ward It is therefore proposed that capital work is completed to facilitate inpatient care delivery in one larger mixed sex ward. This would also free up underutilised space on the hospital site for new service developments. November 2015 Public Board

18 7.11 Until such time as the capital work is completed, both wards will continue to work to their existing establishments. A revised future establishment for one ward is shown in Appendix Four. Minehead 7.12 Minehead Hospital currently works with fourteen inpatient beds in a first floor ward. The hospital is the most remote hospital with Taunton and Somerset Hospital at least 45 minutes away by car. The local population includes large numbers of frail elderly patients The Minor Injury Unit is situated on the ground floor and is the only 24 hour MIU provided by the Trust in Somerset. The attendance is considerably higher in the summer months however overnight attendance is consistently low after midnight The current establishment on the ward for night duty is for 2 RGNs. It is proposed that the number of registered nurses on duty at night is reduced and a new twilight shift is trialled, with RGN cover provided by the Minor Injury Unit after this time. South Petherton 7.15 South Petherton has been working with sixteen stroke beds due the problem with recruiting registered nurses. In October the Trust agreed to re-open eight primary care beds to support patients who are fit for discharge The establishment has therefore been updated to reflect the new number of beds and case mix of 24 patients. Bridgwater 7.17 Bridgwater has been working at 21 beds and will be increasing to 26 beds over the winter period. A revised establishment to include a trial of a new twilight shift has been developed. Chard and Crewkerne 7.18 Both Chard and Crewkerne hospitals have struggled to recruit registered nurses and will each have Spanish Nurses working on the ward shortly. It is proposed that each ward establishment now has a band 6 in addition to a band 7 in order to provide additional ward leadership during the 9am to 5pm period. It is anticipated that these posts will be converted from Band 5 posts and will be more attractive in terms of recruitment. Frome 7.19 Frome has been able to attract four newly qualified staff and provides a GP assessment bed in addition to primary care beds. The establishment has been revised to include a trial of a new daytime midshift. November 2015 Public Board

19 Shepton Mallet 7.20 Shepton Mallet predominantly functions as a 13 bed ward now that the ESD team is established and functioning well. It is proposed that the ward establishment is amended to reflect this with staffing enhanced proportionately (usually from the ESD team) by the ward sister when additional patients are admitted. West Mendip 7.21 West Mendip has now been functioning as one ward for at least six months with both a Band 7 and Band 6 ward sister. The ward establishment has been amended to trial a new 12 to 8pm mid shift in order to cover busy times on the ward. Williton 7.22 Williton is an established stroke and primary care mixed ward and has struggled at times to recruit registered nurses. The establishment has been reviewed and amended to reflect staffing needs at each time of day. 8. MENTAL HEALTH INPATIENT WARDS 8.1 As per each of the previous reviews, all mental health ward managers have utilised the Staff Matrix Tool (based on Keith Hurst ) working with the Head of Division and the Acting Head of Mental Health Nursing to determine the appropriate number and mix of clinical professionals required for each shift on the ward. 8.2 In June 2015, NHS England published the Safer Staffing Framework for Mental Health Wards which was commissioned specifically to equip mental health ward leaders with the skills and knowledge to plan and deliver safe staffing. It is based largely on patient dependency ratings whilst allowing for moderation on a shift by shift basis through professional judgement. It also provides a means of assessing the service against agreed best practice. 8.3 In order to evaluate the cost and benefit of applying the national framework within the Trust, it is proposed that it is piloted on three wards Holford, Rydon 2 and Pyrland 2. In order to support this, the Trust has secured Keith Hurst, the national lead for the mental health staffing framework to attend and provide training in early December 2015 for ward leaders, operational managers and performance leads to support these wards in the application of the evidence based dependency tools that were endorsed by NHS England in July The general consensus from ward managers is that the current staffing levels for each shift are largely appropriate and safe. There are however two areas where each ward manager has identified November 2015 Public Board

20 constraints and these relate to the supervisory status of Band 6 x junior sisters/clinical leads and the lack of bank budget. 8.5 In May 2014, the Trust Board report identified that Band 6 staff were working between 50% and 80% of their hours clinically and agreed that the role should be standardised to work 100% clinically. Likewise the report identified that Band 7 ward managers had a variety of allowances for supervisory time and an analysis of roles and responsibilities resulted in an allocation of supervisory time for each ward manager ranging from 40% on Magnolia to 80% on Rydon ward. 8.6 In 2014 these two actions served to release additional clinical resource into the ward rota in order to support the identified requirement for an additional 19.4wte RMNs on the ward. It also went some way to standardise the supervisory allowance across both mental health wards and community hospitals where ward sisters had a universal 20% standard supervisory allowance. 8.7 It is has become increasingly evident that deputy/ward managers who were previously not rostered to work clinically and had allocated supervisory time, were often filling the vacant shifts. By reducing their supervisory hours the Trust has by default reduced an element of this flexibility. 8.8 All mental health wards have raised concerns regarding the availability of bank staff and the responsiveness of the bank office. Additional temporary staff are often required to support enhanced observation levels for specific patients which can usually be met with the use of health care assistants rather than registered staff. Capacity issues are now being partly addressed through the recent development of a HCA relief team with staff deployed to wards on a shift by shift basis. 8.9 In the last six months Rydon ward has reported a large number of challenging patients who have been on enhanced observations. This has been compounded by a larger number of newly qualified and inexperienced members of staff. This has required careful risk assessments to ensure that the staffing mix meets the patient dependency levels. A request to trial a reduction to the overnight establishment from two RMNs to one, has not been supported due to the nature of the ward which is a 15 bedded acute admission ward required to admit acutely unwell patients for assessment over the 24 hour period There has been an increasing flexible approach to use of staff across wards on the Taunton site which has been helped with the new Clinical Manager working across Holford and Rydon. He holds regular meetings with the Band 7 ward sisters/charge nurse which has facilitated a more flexible approach to staffing across both wards based on bed occupancy and dependency of patients. It is November 2015 Public Board

21 recommended that this should now be considered for the Broadway Park site Recruitment to mental health wards remains variable with St Andrews particularly benefitting from its closeness to Bath and Bristol. All other wards currently have unfilled vacancies supported by active recruitment campaigns. A key concern remains the loss of experienced ward staff who are choosing to work in new roles within the Trust. Rotational schemes are currently under development to support and retain staff who would like to pursue this Pyrland Ward 1 and 2, struggles to recruit registered nurses and currently operates as separate organic and functional wards. National best practice supports this approach and whilst the temptation is to merge both wards into a single larger ward, this could not be clinically justified. It is recommended that further work is completed to review the older persons pathway in its entirety and consider the option of reducing the number of inpatient beds. In the interim the ward manager has confirmed that the current staffing establishment is appropriate. In recognition that patients on older person s mental health wards usually have additional physical health needs, Magnolia has successfully recruited an RGN to the ward team and it is recommended that Pyrland also considers this Staffing levels on Holford ward have been significantly challenged due to an individual patient with complex health care needs who consistently requires enhanced observation and the deployment of bank and agency staff. This has affected the flexibility of rostering as substantive staff are required to support agency staff. This has meant increased restrictions to shift patterns and has had a negative impact on morale. It is anticipated that this will be resolved shortly. The ward manager reports that the substantive establishment is appropriate for the ward and benchmarking against eight other PICU s would support this. Recommended Changes to the Establishments Magnolia 8.14 This year Magnolia Ward has consistently struggled to staff the ward at the recommended level for 14 beds, due to vacancies, maternity leave and ongoing sickness levels. With a vacancy factor approaching 50% the Trust raised their concerns with the CCG who agreed that the number of beds should be reduced to ten beds from July The revised staffing establishment for the ward based on ten beds is achievable and is attached for formal approval. It is recommended that any cost saving is ring fenced into a ward bank budget. November 2015 Public Board

22 Wessex Ward 8.15 The commissioned contract is for twelve beds and is currently operating on ten beds due to the difficulty in recruiting staff. There are higher levels of reporting to the specialist commissioning group at NHS England due to the high national profile of CAMHs services. At the time of opening the establishment was agreed with NHS England and benchmarked against national standards which are often for larger wards than Wessex House Feedback from the ward manager indicates that the uplift in the establishment between 10 and 12 beds may not be required for the early shift when the young people are predominantly in school. It is therefore proposed that the establishment remains unchanged but the additional posts for twelve beds are not recruited to substantively, instead using professional judgement and risk assessing based on bed occupancy and dependency and utilising temporary staffing where this is indicated. This information would be used to inform the next skill mix review. Ash Ward 8.17 Ash ward is a 12 bedded low secure ward with a relatively stable cohort of patients requiring largely recovery based interventions and support with community integration. For the last six months the ward has struggled to meet the recommended RMN staffing level for each night shift and has risk assessed based on bed occupancy and dependency. When clinically indicated, the ward manager has brought in a bank or agency RMN. The risk assessments have indicated that a more flexible approach to staffing the night shift on the ward is appropriate utilising the staff available on both Willow and Wessex House wards which are adjacent to the ward for any unplanned escalation in care needs Following discussion with the ward manager it is recommended that the establishment for Ash ward is amended to reduce the number of RMN on duty from two to one. When required, they will roster a third HCA or a second RMN on duty at night. The savings from this change should be ring fenced into a ward based bank budget to be utilised for additional temporary staffing when the dependency indicates that this is appropriate. The risk will be further mitigated by formalising the cover arrangements between the three wards and in particular Wessex House where there are always two RMNs on duty. November 2015 Public Board