Nursing and Midwifery Establishment review April 2017 Page 1

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1 Trust Board - July 217 Agenda Item: Nursing and Midwifery Establishment Review PURPOSE PREVIOUSLY CONSIDERED BY To provide the Board with the bi-annual review report for ward establishments for April 217 Elements of content previously considered by the Nursing and Midwifery Executive Committee (NMEC) and Ward Sisters and Matrons Committee and the Risk and Quality Committee (RAQC) Objective(s) to which issue relates * Keeping our promises about quality and value embedding the changes resulting from delivery of Our Changing Hospitals Programme. Developing new services and ways of working delivered through working with our partner organisations Delivering a positive and proactive approach to the redevelopment of the Mount Vernon Cancer Centre Risk Issues(Quality, safety, financial, HR, legal issues, equality issues) Healthcare/ National Policy (includes CQC/Monitor) Poor quality patient experience Impact on safety Impact upon annual assessment ratings Non-compliance with regulatory and legislative requirements Trust reputation CQC standards, NHSLA standards, NICE Guidance Safe Staffing for nursing in adult in patient wards in acute hospitals (214). NICE Guidance Safe midwifery staffing for maternity settings (215). National Quality Board How to ensure the right people, with the right skills, are in the right place at the right time. (213) NHSI-Model Hospital Dashboard (217) CRR/Board Assurance Framework * * tick applicable box Corporate Risk Register BAF ACTION REQUIRED * For approval For decision x For discussion For information DIRECTOR: Director of Nursing and Patient Experience / DIPC PRESENTED BY: Director of Nursing and Patient Experience / DIPC AUTHOR: Liz Lees, Director of Nursing and Patient Experience / DIPC DATE: July 217 We put our patients first we work as a team we value everybody we are open and honest We strive for excellence and continuous improvement Nursing and Midwifery Establishment review April 217 Page 1

2 Nursing and Midwifery Establishment Review April 217 Nursing and Midwifery Establishment review April 217 Page 2

3 Nursing and Midwifery Establishment Review Trust-wide 1. Executive Summary The data collection for the nursing and midwifery establishment review was undertaken in April 217. Actual staffing, along with patient acuity and dependency data, was collected over a 2 day period. This was then analysed using a recognised evaluative framework, and was benchmarked against other Trusts - Appendix 1. Triangulation of this data, along with nationally recognised recommendations, are used to assess appropriate nurse staffing levels for each inpatient ward. The Trust uses a flexible and pragmatic approach to safe staffing, using evidence-based tools and appropriate skills mix to assess and meet the overall need in all departments. This establishment review outlines the work undertaken since the last review, provides an update on any continuous or on-going initiatives and outlines any future options to be undertaken in relation to maintaining safe and productive nurse staffing levels. Summary of additional options reviewed:- Review staff modelling within the Stroke service. Review of staffing shift plan and skill mix on the Acute Cardiac Unit (ACU). Review of staffing shift plan and skill mix on ward 5A. Review of staffing shift plan and skill mix on Swift ward. Review of staffing shift plan and skill mix on ward 8B. Review of staffing shift plan and skill mix on the Short Stay Unit (SSU). Review of staffing shift plan and skill mix on Ashwell ward. Incorporating the Trainee Nurse Associates into the nursing workforce. Update on the Enhanced Nursing Care Team. Aligning budgets to clinical models 2. Introduction Trust Boards have a duty to ensure safe staffing levels are in place and patients have a right to be cared for by appropriately qualified and experienced staff in a safe environment. These rights are set out within the National Health Service (NHS) Constitution, and the Health and Social Care Act (212) which make explicit the Board s corporate accountability for quality. The Nursing and Midwifery Council (NMC) sets out nurses responsibilities in relation to safe staffing levels. Demonstrating safe staffing is one of the six essential standards that all healthcare providers must meet to comply with the Care Quality Commission (CQC) regulation. This is also incorporated within the NICE guidelines Safe Staffing for nursing in adult inpatient wards in acute hospitals (214). The Carter report (215) recommends the implementation of care hours per patient day (CHPPD) as the preferred metric to provide NHS trusts with a single consistent way of recording and reporting deployment of staff working on inpatient wards. Although not directly referenced within this report, other quality indicators have been taken into consideration, i.e. red flags, red triggered shifts and the Nursing and Midwifery Quality Indicators. These indicators are considered and reported within the monthly safe staffing report. Nursing and Midwifery Establishment review April 217 Page 3

4 3. Purpose This establishment review was undertaken for a number of reasons, including:- The need to provide assurance, both internally and externally, that ward establishments are appropriate to provide safe care to patients. To provide establishment data that will inform the Trust Workforce Strategy and People Strategy To deliver Care Quality Commission requirements under the Essential Standards of Quality and Safety, including outcomes 13 (staffing) and 14 (supporting staff). To support implementation of the Trust s annual and strategic objectives, the Nursing and Midwifery Ambitions and Patient and Carer Experience Strategy. 4. Summary of key actions implemented following previous establishment review A Summary of actions implemented in previous establishment reviews can be seen in Appendix Establishment review methodology A full review of the data, collection processes and methodologies can be found in Appendix Current assumptions Skill Mix and Registered Nurse to bed ratio The nurse to patient ratio describes the number of patients allocated to each registered nurse. Nurse patient allocations are based on the acuity or needs of the patients on the ward. In critical care the ratio may be 1:1 for the sickest patients or 1:2 or 1:3 for patients who are acutely ill but stable. On general wards the nurse to patient ratio is higher, for example 1:6 or 1:8 depending on the type of service delivered and the needs of the patients. This type of nurse patient ratio is based on guidelines from professional organisations and accreditation bodies, but also reflects the needs of the individual patients at a given point in time. A full ward breakdown of the service model skill mix and the actual worked skill mix for the reference period can be found in Appendix 4. The Royal College of Nursing (RCN) Mandatory Nurse Staffing Levels (212) and NICE Safe staffing for nursing in adult inpatient wards in acute hospitals (214), suggest wards have a planned registered nurse to patient ratio of no more than 8 patients to one registered nurse on day shifts. Table 1 below indicates the service model average target registered nurse to patient ratio for the Trust, the table indicates that no division has a model registered nurse to patient ratio of more than 1 to 8. Table 1 Registered Nurse to Patient ratio per division Division RN to Bed Ratio Early Late Night Medicine 1/5 1/6 1/7 Surgery (Excluding Critical Care) 1/6 1/7 1/8 Women's and Children's 2/9 2/9 2/9 Cancer 1/5 1/6 1/7 Nursing and Midwifery Establishment review April 217 Page 4

5 7. Data Triangulation 7.1 Care Hours per Patient Day (CHPPD) At ENHT care hours per patient day (CHPPD) is a productivity model that has been used, in triangulation with other methods, to set the nursing and midwifery establishments. The review of NHS productivity, chaired by Lord Carter, highlighted CHPPD as the preferred metric to provide NHS trusts with a single consistent way of recording and reporting deployment of staff working on inpatient wards. The methodology for calculating CHPPD used in this review can be found in Appendix 3. CHPPD includes elements of care time that are categorised as direct and indirect clinical care time, these include: Direct patient care time All hands-on care (for example assistance with eating and drinking, patient hygiene, administering medication, taking clinical observations) Providing one-to-one observation or support to patients (for example, taking them to or from theatre) All direct communication with patients Indirect patient care time Patient documentation Professional discussions to plan patient care Discharge planning Communication with patients relatives and friends Ordering investigations Shift handovers CHPPD is used prospectively to identify the likely care time required for expected patient type for a service; this can then be compared to the required CHPPD for actual patients using the service. This can then be compared to the actual CHPPD provided by staff on the ward to asses if wards were appropriately staffed for actual patients. Table 2 below shows the three dynamics of the continuous linear CHPPD cycle. A full breakdown per ward can be seen in Appendix 5. The analysis of outlier wards are discussed further in this report. Table 2 Care Hours per Patient Day service model, required, and actual worked per division Division Service Model CHPPD Required CHPPD SafeCare Actual worked CHPPD Medicine Surgery (Excluding Critical Care) Women's and Children's Cancer Safer Nursing Care Tool (SNCT) The SNCT is an evidence-based tool developed to help NHS hospitals measure patient acuity and dependency to inform decision making on staffing and workforce, this tool has an expected 1% variation. Nursing and Midwifery Establishment review April 217 Page 5

6 Table 3 below shows the occupancy information for each division for the sample period; the SNCT recommended establishment (whole time equivalent - WTE) adjusted to include 17% headroom, current recruitable establishment and the variance between the two metrics. The table shows the cumulative divisional position. Table 3 Divisional bed occupancy, SNCT, recruitable establishment and variance Division Bed Occupancy % Recommended SNCT recruitable WTE based on occupancy (headroom adjusted to 17%) Recruitable Establishment (17% headroom) Variance from actual funded WTE Medicine 93% Surgery (Excluding Critical Care) 86% Women's and Children's 65% Cancer 61% As the SNCT has an expected variation of 1% Medicine and Surgery fall within this expected range, Women s and Children s and Cancer have variations of 56% and 42% respectively, this is due to the fall in occupancy during the establishment review period. A full breakdown of the data for each ward can be found in Appendix 6. When using this tool, other variables should also be taken into consideration: Clinical speciality Staff capacity, capability, seniority and confidence Organisational support and support roles Ward manager supervisory time The outlying variances are discussed per individual unit further in the report SafeCare SafeCare has been used since October 215 to provide the safer nursing care data for the establishment review. Acuity/dependency is measured on all inpatient wards three times a day and recorded on SafeCare. SafeCare allows nursing staff to capture actual patient numbers by acuity and dependency and asses if staffing levels are appropriate. SafeCare provides visibility across wards and areas transforming rostering into an acuity based daily staffing process that unlocks productivity and safeguards safety. SafeCare has been awarded an endorsement statement by NICE as an effective tool to support Safe Staffing. The Trust is a national leader in the use of SafeCare for safer staffing; having hosted over 35 Trusts to observe and share the Trusts practices and processes to ensure wards are staffed safely Data Validation To validate data collection for the establishment review, the following actions were taken: Inter-rater reliability training - To ensure that the SNCT data is validated and consistent, interrater reliability exercises have been undertaken with the nursing teams to ensure consistent application of the acuity multipliers. Comparing recommended establishment for both CHPPD and SNCT Appendix 7. Matron Acuity Audits - Throughout the data collection period Matrons audited their wards on a weekly basis to validate data inputs. Any discrepancies in the acuity data scoring were corrected and Matrons worked with nurses to ensure consistent application of the tool. Nursing and Midwifery Establishment review April 217 Page 6

7 External benchmarking with other organisations using the NSH Improvement (NHSI) Model Hospital Dashboard Nursing and Midwifery Quality Indicators The Trust uses information and statistical tools to examine indicators of care. These indicators include; pressure ulcers, complaints, patient falls, drug administration errors, Clostridium-difficile rates, MRSA rates. Standardising these metrics by occupancy and length of stay creates a statistical tool that highlights outlying areas whose indicators are higher than anticipated. Any indicator triggering above established threshold is subject to detailed analysis and an action plan developed where appropriate to improve patient safety and experience. A summary of the nursing and midwifery quality indicators for April 217 can be seen in Appendix Red Triggered Shifts The Trust monitors and reports shifts that fall below minimum staffing levels (red triggered shifts) on an on-going basis. Appendix 1 shows the percentage of shifts that fell below minimum levels during the establishment review period. Proactive mitigating action is taken by nursing team to balance risk across the organisation. Factors affecting red triggering shifts include: Patient numbers, dependency and acuity Staffing number and skill mix Temporary Staffing fill rate Vacancy Rate Sickness Enhanced Nursing Care requirements (Specialling) 8. Aligning budgets to clinical models There has been on-going challenges with the alignment of financial budgets against the clinical modelling of nursing rosters. A comparison between funded establishment and shift plans data in May 217 confirmed these discrepancies which will be addressed as part of the re-launched establishment alignment group. The differences found within the Stroke Services were significant and have been aligned by the Division as part of the CIP plans. Reduction in WTE (Stroke Services) 1WTE Band WTE Band 5 Change in Budget 352, 151, It is important to note that the information in this and previous establishment reviews is what was on the clinical service model for each unit has been available to roster. Therefore any funding discrepancy has not affected the safe delivery of care. 9. Departmental Reviews 9.1 Maternity The following is based on 216/217 clinical activity The current clinical funded workforce with the uplift of 7.76wte is *midwives and 12.1 support workers* 93/7 split ratio of 1:29.5 To achieve a ratio of 1:29 requires an establishment of 174.3wte Midwives and 19.4wte Support Workers Support Workers referred to are Band 3-4 and do not replace the existing band 2 Clinical Support Workers (CSW s) Nursing and Midwifery Establishment review April 217 Page 7

8 Strategy Phase 1-Utilisation of the establishment uplift Uplift is to meet CQC recommendations and support compliance with fetal surveillance national recommendations A phased approach is being undertaken as midwives are recruited so that agency staff are not used to fill these posts Band 5 Midwives added to the CLU shift plan to staff Triage 11.5 hours 7 days a week - completed 1 Band 6 to support the increase in the opening hours in DAU 1 Band 3 to support the increase in the opening hours in DAU Phase 2 Achievement a 1:29 Ratio Convert the remaining funded band 5 establishment to support an uplift of Band Emergency Department (ED) Following the October 216 review it was recommended that the ED decrease their band 5 establishment by 15 WTE. A phased reduction to support these changes has been implemented resulting in a reduction week-on-week of temporary staffing spend. The new shift plan was modelled on incremental activity over a 24 hour period which has also supported new ways of working which has contributed to improved ED performance. 9.3 Bluebell Children s Ward Children s services have always flexed the nursing and support staff on Bluebell ward in relation to patient numbers and acuity. Bluebell ward works closely with the children s emergency department and outpatient services to support the whole paediatric unit ensuring all areas are safely staffed. From April 217 operational beds on Bluebell ward have been reduced to 16 open beds/cots (from 2). This is for a number of reasons: Reduced bed occupancy over the summer period Vacancies across children s services Change in acuity and dependency of patients Staff in the pipeline starting in September 217 The service has monitored activity and found that shifts were not being filled adequately with temporary staff on the unit. A risk assessment was carried out and a decision made to operate at 16 beds until September 217 when new staff will be starting. This change in bed numbers takes into consideration the potential change in acuity of patients going into the winter period where it is likely to see an increase in admissions, particularly patients with respiratory conditions. Staffing levels have been adjusted to support a reduction of inpatient numbers, staffing ratios remain within paediatric guidelines and the service are able to flex the team across the unit to maintain safe staffing levels. Figures presented in Appendix 6 of this report have been calculated with 2 operational beds on Bluebell ward and therefore the decrease in staff should be considered alongside the notes above and with the understanding that Bluebell ward will keep some posts vacant and staff to the 16 bed shift plan. The amount that will be held is the equivalent of 4.29 WTE. To achieve this, the division will: Delay recruitment from April to September as well as withhold temporary staffing during this period. Reduce 1 band 5 shift per day and night on Bluebell ward, Decrease the bed capacity from 2 to 16. Nursing and Midwifery Establishment review April 217 Page 8

9 This cost improvement measure to be in place for a period of 6 months will generate a cost saving of 83,31. Reduction in WTE Cost saving , Mount Vernon Cancer Centre - Wards 1 and 11 As a consequence of reduced length of stay and the introduction of alternative ways of working, the inpatient beds at MVCC have been reduced from 45 to 36 beds across both inpatient wards. The staffing roster has been adjusted to reflect this change and combined onto one roster, this was ratified in March 217. There is scope to further reduce the inpatient beds to 22 and house an ambulatory care unit in the other inpatient ward area. Work is being undertaken to facilitate the new service. Subject to formal agreement by the Trust to implement the new models of care, both shift plans for the 22 inpatient beds and the ambulatory care unit will need to be approved by the Director of Nursing. This equates to a reduction which has resulted in a cost saving of Reduction in WTE 1 band 7 WTE, 7.27 band 5 WTE, 3.36 band 2 WTE Cost Saving 354, 9.5 Stroke The stroke service at the Trust includes both Hyper Acute Stroke and rehabilitation services located on Pirton and Barley wards; between them they have 46 beds. As part of national guidelines the trust is considering the best way to serve patients utilising multidisciplinary team (MDT) approach to new ways of working and collaborative work with Hertfordshire Community Trust (HCT) to incorporate Allied Health Professionals (AHPS) into the care hours on the Stroke unit. Current AHP cover for the service is not included in the CHPPD and the trust is part of a national pilot to explore how MDT working can improve patient care and outcomes for our stroke patients. To support this new way of working this establishment review proposes a more combined approach to a way the 2 stroke wards operate, having a single ward manager (band 7) working in a supervisory capacity will help to bring the services together. This would be a reduction of 1 Band 7 WTE, Changes in WTE Reduction of 1 band 7 And uplift.75 band 6 Cost Saving 14, Acute Cardiac Unit (ACU) Since the last establishment review, a service reconfiguration of the cardiology service based on activity has resulted in a 12 bed reduction to 22 (from 34) inpatient cardiology beds. Since this reconfiguration ACU SafeCare has consistently indicated that the unit is overstaffed for the bed occupancy and dependency and acuity of their patients - Chart 1. Nursing and Midwifery Establishment review April 217 Page 9

10 Chart 1 - ACU: required vs Actual CHPPD Consideration has been given to the geographical layout of the unit and skills mix of service. On this basis this review recommends the shift plan change to 4 Registered Nurses and 2 Clinical Support Workers 24 hours per day. Changes in WTE Reduction of 4.91 band 5 WTE and increase 2.46 band 2 WTE Cost savings 9, Ashwell Ward Ashwell ward is a 24 bed frailty ward that flexes 28 beds when escalation beds are required. Chart 2 shows the CHPPD for Ashwell ward had less care hours than were required for the acuity and dependency of their patients. Chart 2 - Ashwell: Required vs Actual CHPPD This ward had a higher than expected number of patients requiring enhanced care during the data collection period, which is reflected in the SNCT data. Ashwell ward also flex staffing in line with the opening of 4 escalation beds as required, although service models are based on the service model of 24 patients. This review recommends a wait and watch approach to Ashwell, using the flex and reactive support process currently in place. However it is worth noting that this is not the most cost effective Nursing and Midwifery Establishment review April 217 Page 1

11 model or safest model if the unit continues to utilise the escalation beds, if these escalation beds are continually used the service model should be updated to reflect the used occupancy. 9.8 Short Stay Unit (SSU) SSU had a higher than expected number of patients requiring enhanced care, which is reflected in the SNCT data shown in Appendix 5. The rise in acuity is clearly shown in Chart 3 from 16 April 217. Chart 3 - SSU: Required vs Actual CHPPD This spike in acuity along with higher than expected sickness levels (12%) and parenting leave (6%) resulted in a higher number of red triggered shifts in April compared to other months, although these were mitigated in line with the Trusts Safer Staffing Policy. This spike in acuity is not consistent with the continuous data collected over the last 6 months and therefore this review recommends a wait and watch approach, focusing on acuity and dependency to ensure these results are not part of a trend change in the service. 9.9 Ward 5A Ward 5A is a 3 bed trauma and orthopaedic ward, chart 7 shows the ward have marginally more CHPPD than was required for the actual patients on the ward. Following discussion with the ward team, this review recommends a change in skill mix on the late shift, taking them from 5 RNs and 2 CSWs to 4 RNs and 3 CSWs. The ward manager has historically been rostered for 5 supervisory days a week compared to her peers who are rostered 3 per week. There was no reason identified for this difference and therefore it is recommended that this is adjusted to 3 supervisory days on 5A to provide a consistent model across the ward areas. Nursing and Midwifery Establishment review April 217 Page 11

12 Chart 5-5A: Required vs Actual CHPPD In addition to the skill mix review, comparable surgical wards have a band 6 on overnight at the weekend to provide consistent senior clinical cover out of hours and therefore this review recommends 5A put a band 6 on weekend nights and remove a band 5. Skill Mix Change Reduction of 2.29 band 5 WTE, increase 1.18 band 2 WTE and.72 band 6 WTE Cost savings 16, Swift Ward Over the last 6 months and during the establishment review period Swift ward appeared to be over established based on the actual occupancy, dependency and acuity of patients on the ward chart 6 below. When considering the geographical layout of the unit and after discussing with the team, this review recommends a reduction in staffing. Staffing will reduce by one CSW on a long day shift 7 days a week and 1 RN at weekend to reflect the service. Chart 6 - Swift (Early): Required vs Actual CHPPD Reduction in WTE Cost savings.39 band 5 WTE and 2.14 band 2 WTE 49, Nursing and Midwifery Establishment review April 217 Page 12

13 9.12 Ward 8B 8B is a 3 bed general surgical and vascular ward. During the establishment review the SCNT indicated the funded establishment was lower than the recommended establishment appendix 7. Benchmarking data taken from the NHSI model hospital dashboard shows that the care hours are lower than national median for a similar service. (Appendix 8) There is an indication that an increase in CHPPD may also support an improvement in the nursing quality indicators in conjunction with the ward action plan. This review recommends, an increase of 1 CSW for the night shift taking the ward to 4 RNS and 2 CSWs. Chart 7-8B: Required vs Actual CHPPD Increase in WTE Cost 2.46 band 2 WTE 46,18 1. Trainee Associate Nurse (TNA) Pilot This new nursing support role works alongside healthcare support workers and registered nurses to deliver hands on care, ensuring patients continue to get the compassionate care they deserve. Nursing associates support nurses to spend more time using their specialist training to focus on clinical duties and take more of a lead in decisions about patient care. The NMC (217) stated The intention is for nursing associates, who will have foundation degrees, to contribute to the delivery of patient care. The registered nurse will still have responsibility as the primary assessor, planner and evaluator of care. Nursing associates will support, not replace, registered nurses. The NMC have agreed to regulate this role. Hertfordshire and West Essex STP became a pilot site for the new Trainee Nursing Associate (TNA) programme. Across the STP 53 Trainees have commenced this programme, of which 17 are from ENHT. The TNA programme is a two year work based learning programme with one day a week attendance at University. The TNA works under supervision of the registered nurse delivering effective, safe and responsive care. On successful completion of the course the Nursing Associate will be able to work independently, within defined parameters of practice. The course commenced in April 217, with the TNAs allocated to wards. These wards shift plans have been reviewed to ensure wards have enough registered nurses, and the TNAs have the support to train in this new role. The TNAS will be working 7:3 to 15:3 Monday to Friday with a study day on a Thursday. This has been the safest option when looking at registered nurse to patient ratios. All adult wards that support a TNA have had a reduction of a band 5 on an early shift that is now covered by a TNA. The ward managers are supervisory for 3 of those days to support the wards and the matrons are expected to work clinically once a week. All wards have a Nursing and Midwifery Establishment review April 217 Page 13

14 Registered nurse to patient ratio within the national recommendations. Risk assessments have been completed and a process put in place to agree additional RN support by the Director of Nursing if patient acuity and dependency is higher than expected on all wards. The scoping and initial costings undertaken from the last establishment review have been adjusted and re-evaluated Appendix4 Table 2. This has resulted in a cost saving between Bluebell ward and the general wards of 85,. Acute Medical Unit Ward (AMUW) The risk assessment completed following the introduction of the TNA role, has highlighted that the skill mix in this area, on the days that the ward manager is not supervisory, may not be adequate. This is largely due to the admission criteria, high turn around of patients and the geographical layout which consists of 1% side room accommodation. It is therefore recommended that the ward manager is supervisory five days a week instead of three to ensure the unit is staffed safely. This will be reviewed again in six months. Skill Mix Change Cost Uplift.39 band 5 1, Enhanced Nursing Care Team Following agreement of the 9.56 WTE uplift within the team from the last establishment review, by August the team will be fully recruited too and will cover most specialling requirements in the Trust. The team has contributed to the following benefits; More hours of care at reduced costs Reduction in agency spend Falls reduction Harms reduction Higher level of care for vulnerable patients Preventing deconditioning Robust process for enhanced care Rotation of staff to most high risk patients Specialist training Involving carers Promoting independence Reduced length of stay Improved compliance with MCA and DOLs Use of volunteers for enhanced care Least restrictive care requirement for vulnerable patients Introduction of Bay watch The Enhanced Care Team have been chosen as a case study for NHSI, and are working with the Advisory Board Research Team to profile the work the team have done. The team are working with Hertfordshire Partnership Foundation Trust (HPFT) to pilot supporting mental health patients requiring enhanced care while in the acute trust. Additional training will be delivered to support this collaborative work. The team have hosted numerous visits to share the good practice with other Trusts who are keen to implement a similar model. For the full report see Appendix 11 Nursing and Midwifery Establishment review April 217 Page 14

15 Summary of proposed changes from the Establishment Review WTE movement 5A Swift 8B ACU Combined Stroke AMU-W Total Nurse band Nurse band Nurse band Nurse band Nurse band 2 (CSW) Admin & Clerical band Ancillary band movement 5A Swift 8B ACU Combined Stroke AMU-W Total Nurse band 7-41,637-41,637 Nurse band 6 25,74 26,746 51, Nurse band 5 63,54 1,62 139,383 1,62 22,438 Nurse band 4-39,6 46,18 46,18 74,55 Nurse band 2 (CSW) 21,475 Admin & Clerical band 2 Ancillary band ,55 49,625 46,18-93,366-14,891 1,62 117,75 Summary of additional approved CIP s Department WTE Reduction Mount Vernon Band 7 1 Band Band Stroke Services phase 1 alignment of budget to shift plan Band 5 1 CIP values as per PID CIP Ref (full year numbers effect) 354, CAN , MED Stroke Services phase 2 - alignment of budget to shift plan Band , MED Bluebell Seasonal variation (6 month effect) Band ,31 WAC Trainee Nursing Associate Bluebell Adult 36, 49, WAC CORP-NU Total 1,25, Summary and Recommendations for Executive Approval Nursing and Midwifery Establishment review April 217 Page 15

16 On balance, reviewing all available information, this review suggests that current funded establishments are appropriate to provide safe nursing care on most inpatient wards. However, based on the information in this report, the following recommendations should be considered:- Align all budget to agreed safe staffing models for the service Introduce a whole service approach to the stroke service Update on Maternity staffing Skill mix change on ACU Skill mix change on ward 5A Skill mix change and staff reduction on Swift ward Uplift of 1 CSW on a night shift on ward 8B Implementation on the pilot of Trainee Nurse Associates Closely monitor ( Wait and watch ) staffing, patient acuity and dependency on a continuous basis on the following wards: SSU Ashwell Wait and watch will remain in place until the next establishment review 13. Next Steps Explore the season variation of acuity and dependency for services to ensure proactive planning for seasonal changes. Develop Apprenticeships and the band 3 and 4 roles on all wards in line with national guidance. Develop the Nursing Associate pilot. Work with NHSI to develop the model hospital dashboard. Collaborative working with HPFT to support mental health patients in the acute trust. Collaborative working with the learning disability team to support LD patients in the acute trust. Explore multidisciplinary team (MDT)ways of working. Scoping exercise looking at a combined model of working in the assessment units (Acute Medical Unit and Surgical Assessment Unit) Benchmarking review into Theatres staffing with possible scope to remodel the workforce Review of specialist and non-ward based nurses roles and services External review into remodelling the outpatients department. Review of Critical care staffing The Trust Board are asked to approve the recommendations in this report. References: Carter (215). Productivity in NHS Hospitals. London: Department of Health. Francis R (213) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: Stationery Office NHS England (216). Leading Change and Adding Value: A framework for nursing, midwifery and care staff. London: NHS England NICE (213) Safe Staffing for nursing in adult inpatient wards in acute hospitals. Nursing and Midwifery Establishment review April 217 Page 16

17 Appendix 1 Benchmarking data comparing local peers East & North Hertfordshire NHS Trust (ENHT), Princes Alexandra Hospital (PAH), West Herts Hospitals Trust (WHHT) North Middlesex University Hospitals Trust (NMT) PAH WH T ENH T NMT WH T PAH ENH NM T Nursing and Midwifery Establishment review April 217 Page 17

18 PA H NM T WH T ENH T Nursing and Midwifery Establishment review April 217 Page 18

19 Appendix 2 Establishment Review Summary Year WTE Speciality Costs Establishment Review Medicine 473,2. Establishment Review Medicine and surgery 485,324. Establishment Review Feb 214 Medicine and surgery 991,984. Establishment Review - Oct 214 Establishment Review October 215 Establishment Review April 216 Increase in Band 7 supervisory to 3 days a week 1.16 Increase 1B unregistered day coverage by 2.46 WTE and increase 11A unregistered night coverage by 2.46 WTE All in patient ward managers Paediatrics Medicine Surgery 55,. 21,93. Medicine 124,722. The Enhanced Care Team (Specialling) Corporate 145,. WTE 9.56 Establishment Review Trainee Nurse Associate Pilot All Divisions - 45,. Oct 216 Reduction of band 5 (15) WTE and increase Medicine - 642,. of Band 2 (2) WTE Midwifery increase of 7.76 WTE 287 Women's 287,. Total 2,571,323. Establishment Changes as a result of business cases Year WTE Speciality Costs Full external review of both Children's and Adult Accident & Emergency departments resulted in Emergency an additional 1.5million increase the nursing Emergency Department Business Case establishment and skill mix, this was Department requirement was phased in with full 1,5,. implementation in October /7 Matron Business Case 3 Matron 155,962. Swift Ward funded for 7 days opening. Introduction of the enhanced nursing care team. 7AN Established as part of the trusts Corporate Nursing Interim Establishment operational bed base. Medicine Changes B Established as a 3 bed ward as part of Surgery normal operational activity 961,223. Replace 1 band 5 with 1 band 4 on 24 inpatient wards as a 2 year scoping exercise Total 2,617,185. Total Additional Budget 5,188,58. Nursing and Midwifery Establishment review April 217 Page 19

20 Methodology Appendix 3 The following information was also collected and reviewed; a review of all relevant literature and guidelines was undertaken prior to commencement of this review, these included: NICE Guidance on Safer Staffing for nursing in adult inpatient wards in acute hospitals (212) Compassion in Practice, NHS England (212) Safer Nursing Care Tool Nurse sensitive indicators Safer Staffing Guidance, Trust Development Authority (215) Leading Change Adding Value (216) Lord Carter Report (216) Lord Willis Report (215) As part of this review all calculations were carried out in line with the national guidance associated with these tools. This document details the assumptions, methods of data collection, calculation and evaluation as applied in the establishment review. These are set out for each information process below: Skill Mix: Data for this metric is collected from the approved shift plans defining each service model and actual hours worked on the roster system. It is assumed that the roster template is an accurate representation of the shift plan, that the shift plan is an accurate representation of the service model and that the hours worked on the roster are true reflection of what was worked. The calculations for this metric are: Service model skills mix: Total number of clinical hours available on shift plan for registered/unregistered staff / Total number of clinical hours available on shift plan Actual skills mix: Total number of clinical hours worked for registered/unregistered staff for the reference period / Total number of clinical hours worked for the reference period Registered nurse to bed ratio: The data for this metric is collected from the daily staff sheet and the shift plan, it is assumed that the number of available beds on the daily staffing return is correct and the number of registered nurses on shift on the shift plan is an accurate representation of what could be rostered to work. The calculations for this metric are: Number of registered nurse on shift / Number of available beds for reference period Nursing and Midwifery Establishment review April 217 Page 2

21 Care Hours per patient day (CHPPD) The data for this metric is collected from the service model shift plans, the Trusts e-roster system and SafeCare. It is assumed that the service model shift plan is an accurate representation of the service, the roster is an accurate reflection of the hours worked and SafeCare has accurate patient acuity and dependency scores input for each patient. As SafeCare uses an external formula to calculate the required and actual CHPPD values, it is assumed that this formula is correct and the Shelford Acuity and Dependency model is appropriate for the service. The calculations for this metric are: Service Model CHPPD: Total service model care hours (clinical care hours for registered and unregistered staff) / Total beds Required CHPPD: Required hours of work based on standardised SNCT model / Average patients per 24 hours in reference period (Patient days) Actual CHPPD: Actual Hours Worked / Average patients per 24 hours in reference period (Patient days) Cost of Care Hours per Patient Day: The data for this metric is taken from the same sources as detailed in CHPPD calculations above, along with financial information from the budgeted and actual cost in month for the reference period. In addition to the assumptions made in the CHPPD calculation, it is assumed that the financial information is an accurate account of what is spent in month and that the budget is representative of the nursing spend for inpatient activity. Target cost of care hours: Budget per bed day (Total monthly budget/number of inpatient beds) / Service model CHPPD Required cost of care hours: Target cost of care hours X Variance factor of CHPPD (Target model CHPPD/Required CHPPD) Actual cost of CHPPD: Spend per bed day (Total monthly budget/number of inpatient beds) / Actual worked CHPPD Nursing and Midwifery Establishment review April 217 Page 21

22 Cost distribution of CHPPD: This metric builds on the actual worked CHPPD and breaks this down by how it was funded, highlighting the substantive, bank and agency proportions of how CHPPD is provided. Safer Nursing Care Tool: Calculations for this metric follow the SNCT national guidelines; data collection for this metric is taken from the roster and SafeCare systems. It is assumed that the roster is an accurate reflection of the work carried out and that SafeCare has accurate patient acuity and dependency scores input for each patient. Calculations for this metric are: Bed Occupancy: Total bed days in reference period / Total available beds in reference period SNCT WTE required: Sum of Total number of patient of a specific acuity X SNCT specific multiplier Required SNCT is then adjusted to include 17% headroom Variance from actual funded WTE: Funded WTE Adjusted SNCT Recommended WTE Supervisory Shifts: Data for this metric is taken from the shift plans and the roster system, it is assumed that the shift plan accurately represents the number of supervisory days available for managers to work, and that the data in the roster system is correct. Calculations for this metric are: Supervisory hours worked / Supervisory hours available Nursing and Midwifery Establishment review April 217 Page 22

23 Canc er W& C Surgery Medicine Cancer W&C Surgery Medicine Table 1 The table below shows the registered and unregistered nurse % for each ward: Table 2 Div Speciality Ward Service model registered nurse % Service model unregistered nurse % Actual registered nurse % Appendix 4 Actual unregistered nurse % 9B Care of the Elderly Ashwell A Stroke Pirton Stroke Barley General 6A General 1B Respiratory 11A AN Cardiology ACU Acute AMU Ward SSU Renal 6B General Surgical Spec 8A 11B * B 7B A T&O Swift B ATCC Critical Care Gynae 1A Gynae* Paeds Bluebell Ward Inpatient Ward Michael Sobell House The table below shows the available staff on shift as per the agreed shift plan and the Registered Nurse to bed ratio RN to Bed Ratio Div Speciality Ward Early Late Night 9B 1/6 1/7 1/7 Care of the Elderly Ashwell ^ 1/6 1/6 1/8 9A ^ 1/7 1/7 1/7 Stroke Pirton 2/9 2/9 1/7 Stroke Barley 1/5 1/6 1/9 General 6A ^ 1/7 1/7 1/7 General 1B ^ 1/7 1/7 1/7 Respiratory 11A ^ 1/6 1/5 1/6 7AN 1/7 1/7 1/7 Cardiology ACU 2/9 2/9 2/9 Acute AMU Ward ^ 1/8 1/5 1/5 SSU ^ 1/7 1/7 1/7 Renal 6B 1/5 1/5 1/8 General Surgical Spec 8A ^ 11B * ^ 1/7 1/7 1/7 1/5 1/7 1/7 8B 7B ^ 1/6 1/7 1/7 1/7 1/7 1/7 5A ^ 1/7 1/6 1/7 T&O Swift ^ 1/6 1/6 1/9 5B ^ 1/7 1/7 1/7 ATCC Critical Care** 1 1 6/7 Gynae 7A * 1/5 1/5 1/5 Paeds Bluebell 1/4 1/4 1/4 Inpatient Oncology Ward ^ 1/6 1/6 1/7 Michael Sobell House 1/4 1/8 1/8 * Denotes the number of staff allocated to the inpatient ward areas ** Critical Care staffing is dependant on the patient number and acuity and therefore the available shifts is not representative of required staff ^ Denotes wards with Nurse Associate Nursing and Midwifery Establishment review April 217 Page 23

24 Cancer W& C Surgery Medicine Appendix 5 Div Speciality Ward Service Model Required Actual worked CHPPD CHPPD CHPPD Ward 9A Elderly Care Care of the Elderly Ashwell ward Ward 9B Elderly Care Stroke Pirton HASU Stroke New Barley General Ward 6A General Ward 1B Respiratory Ward 11A Respiratory A Gynae * Cardiology Acute Cardiac Unit Acute Acute Medical Unit Short Stay Unit - SSU Renal Ward 6B General Surgical Spec Gen Surgery Ward 8A Ward 11B Plastics & ENT Gen Surgery Ward 8B Urology Ward 7BN T&O Ward 5A T&O Swift Ward T&O Ward 5B ATCC Critical Care Unit Gynae Gynaecology Ward 1A Paeds Children Bluebell Ward MV Ward Inpatient MV Ward MV M.S.H Inpatient Unit Division Service Model Required Actual worked CHPPD CHPPD CHPPD Medicine Surgery (Excluding Critical Care) Women's and Children's Cancer Nursing and Midwifery Establishment review April 217 Page 24

25 Cancer W&C Surgery Medicine Appendix 6 The table below shows the recommended recruitable WTE based on the benchmark for the service and the average occupancy for the reference period compared to the actual funded recruitable WTE for the period Div Speciality Ward Recommended SNCT Bed recruitable WTE based on Occupancy % occupancy (headroom adjusted to 17%) Recruitable Establishment (17% headroom) Variance from actual funded WTE 9B 99.5% Care of the Elderly Ashwell 91.9% A 99.2% Stroke Pirton 84.5% Stroke Barley 99.4% General 6A 97.2% General 1B 96.% Respiratory 11A 94.3% AN 95.7% Cardiology ACU 78.6% Acute AMU Ward 91.3% SSU 91.1% Renal 6B 93.8% General Surgical Spec 8A 11B * 9.% 88.% B 7B 93.7% 87.3% A 93.5% T&O Swift 65.% B 85.% ATCC Critical Care 76.5% Gynae 1A Gynae * 85.5% Paeds Bluebell 44.5% Ward 1 41.% Inpatient Ward % Michael Sobell House 74.4% Nursing and Midwifery Establishment review April 217 Page 25

26 Cancer W&C Surgery Medicine Appendix 7 The table below shows the CHPPD Benchmark Recommended WTE compared to the SNCT Recommended WTE. CHPPD Bench Marking Data Div Speciality Ward Recommended CHPPD recruitable WTE based on occupancy Recruitable Establishment April 217 Variance form actual funded WTE SNCT recommended WTE SNCT Recommended Data Recruitable Establishment April 217 Variance of operation establishment to SNCT recommended 9B Care of the Elderly Ashwell A Stroke Pirton Stroke Barley General 6A General 1B Respiratory 11A AN Cardiology ACU Acute AMU Ward SSU Renal 6B General Surgical Spec 8A 11B * B 7B A T&O Swift B ATCC Critical Care Gynae 1A Gynae * Paeds Bluebell Ward Inpatient Ward Michael Sobell House * Denotes the number of staff allocated to the inpatient ward areas Division Recommended CHPPD recruitable WTE based on occupancy CHPPD Bench Marking Data Recruitable Establishment Oct 215 Variance form actual funded WTE SNCT recommended WTE SNCT Recommended Data Worked WTE Variance of operation establishment to SNCT recommended Medicine Surgery (Excluding Crit Women's and Children's Cancer Nursing and Midwifery Establishment review April 217 Page 26

27 Appendix 8 Chart to show 8B CHPPD compared to similar services nationally Nursing and Midwifery Establishment review April 217 Page 27

28 Patient Experience Patient Safety Staffing Beds Appendix 9 NURSING & MIDWIFERY QUALITY INDICATORS: Apr 17 Trust Medicine Surgery Women & Children Cancer Total Beds SUMMARY e-roastering Bed occupancy % (at Midnight) % E-roster Deadline Met Net Hours % Net Hours Position % of Actual Annual Leave Funded WTE Actual WTE Vacancy rate % RN Fill Rate (day shifts) Sickness % Agency usage % NULL 1.4 Bank usage % Staff Appraised % (rolling 12 months) Nursing Overtime Statutory Mandatory Training all 9 Competency % Statutory Mandatory Training Overall Coverage % % Shifts Triggered Red in Month - Initial % Shifts Triggered Red in Month - Final.1.6 Inpatient falls (rate per 1 bed days) Inpatient falls resulting in serious harm (rate per 1 bed days) Hospital Acquired Pressure Ulcers (rate per 1 bed days) % News Score Completion News Escalation No. Medication Reported errors % Medication administered as prescribed % Analgesia administered as prescribed Intentional rounding completed Patient Identification Safety Thermometer Patients with harm % of Compliance with Hand Hygiene % Response to Inpatient Survey Help to eat meals/infant Feeding Enough nurses on duty Respond to call bell Pain Control Understand answers from nurses Someone to talk to about worries and fears Enough emotional support from staff Know named nurse Inpatient FFT - % of patients would recommend Inpatient FFT - % of patients would not recommend FFT Response Rate % No.of Complaints Nursing and Midwifery Establishment review April 217 Page 28

29 Cancer Women's & Children Surgery Medicine Division Appendix 1 Period 2/4/17-21/4/17 Speciality Ward Early Late Night INITIAL REDS Number of shifts where staffing initially fell below agreed levels % of shifts where staffing fell below agreed levels and triggered a Red rating Early Late Night Number of shifts where staffing initially fell below agreed levels % of shifts where staffing fell below agreed levels and triggered a Red rating 9A.. Care of the Elderly 9B Stroke General Respiratory Barley 6A 11A Pirton 1B 7AN Cardiology ACU AMU-A Acute SSU AMU-W Renal 6B DTOC / gastro Ashwell A&E ED CDU.. UCC.. Total A.. General 8B SAU Surgical Spec 11B B A T&O 5B Swift ATCC Critical Care 1.. ASCU.. Total Gynae 1A Gynae Bluebell Paeds Child A&E NICU.. Dacre.. Maternity Gloucester.. Mat MLU.. Mat CLU 1.. Total Ward 1.. Inpatient Ward Michael Sobell House.. Total TRUST TOTAL Early Late Night Number of shifts where staffing initially fell below agreed levels % of shifts where staffing fell below agreed levels and triggered a Red rating Early Late Night FINAL REDS Number of shifts where staffing initially fell below agreed levels % of shifts where staffing fell below agreed levels and triggered a Red rating Medicine Surgery (Excluding Critical Care) Women's and Children's Cancer Nursing and Midwifery Establishment review April 217 Page 29

30 Appendix 11 Enhanced Nursing Care Team Purpose The purpose of this paper is 1. To Update the Executive team on the progress of the Enhanced Nursing Care Team (ENCT) 2. To demonstrate the effectiveness of the team in improving patient care, experience and outcomes 3. To demonstrate cost effectiveness and reduced agency spend on enhanced care (specialling) 4. To demonstrate the robust process for managing enhanced care patients Introduction Dementia takes a huge toll on our health and care services. With the numbers of people with dementia expected to double in the next 3 years and predicted costs likely to treble to over 5 billion, we are facing one of the biggest global health and social care challenges - a challenge as big as those posed by cancer, heart disease and HIV/AIDs. (Policy paper prime Minister s challenge on dementia 22) We are seeing an increased demand in the Trust for patients with dementia and delirium, that have enhanced care needs and require 1-1 nursing care to maintain their Safety. Prior to the introduction of the Enhanced Nursing care Team, (ENCT) there was no robust system to monitor, review and enhance our patients that required 1:1 care. The cost and demand for specialling were escalating. Lord Carter (216) recommended that all Trusts should adopt a rigorous policy for managing enhanced care demands. The good practice guide should also replace the term specialling with enhanced care to better reflect this management practice and patient intervention. Overview The Enhanced Nursing Care team is a dynamic team set up to provide enhanced 1:1 care, or "special observation" for patients that are confused due to dementia or delirium and are high risk to themselves or others. The trust has incurred high costs providing special observation to patients requiring 1:1 care. This was historically provided by an agency support worker with very little knowledge of dealing with this type of patient for a 11.5 hour shift. In order to provide a higher level of care, improve patient safety and to mitigate against high agency costs, the ENCT was agreed as part of a business plan for dementia care and a central budget for specialling was established within the Medical Division. This came into effect in January 216. Following the success and impact the team has had in the Trust, an increase in the size of the team was agreed in October 216 establishment review. The team has now been moved into the Corporate Nursing Directorate from April 217 and has had an uplift of 9.52 WTE. This uplift includes four band 4 team leaders to take charge of the team out of hours and a band 3 Nursing and Midwifery Establishment review April 217 Page 3

31 administrative support. The team will be fully recruited to by August 217 and will provide a team of five members of staff on a day shift and five on a night shift to support most enhanced care requirements on the Lister site without the need for agency staff. Where peaks in enhanced care needs occur, that cannot be met by the substantive team or ward based care, there will be the need for additional support from bank staff. To ensure that this demand can be met, work has taken place with NHSP to establish a pool of bank staff with the right skills that can be utilised as required. The team is made up of dementia/delirium trained staff who are available 24hours a day, seven days per week. They provide the special observation and enhanced care to high risk patients and can be moved flexibly around the hospital as required. The team has been provided with tool kits from donations provided by the league of friends and the forget me not appeal. The team provide distraction therapy and other therapeutic techniques to ensure the patients are calm and settled and free from harm to themselves or others. To develop the team and improve the process for enhanced care a specialling steering group meets monthly and feeds back to the workforce strategy group. Process A Virtual ward is used and the 11.5 hour shifts are divided into 3 hour blocks. This ensures that the Nurse rotates every three hours; the benefits to this system are; 1. The staff have a change of environment which may help when dealing with particularly challenging patients. 2. The patients get to see new staff, and have a change to the monotony of their day. 3. The team can cover more patients for different time periods throughout the day. If a patient has a carer with them in the afternoon, or they sleep in the morning, other patients can be supported on other wards at these times. Staff can be moved around the hospital to the high risk patients to meet the demand. Before the team was established the procedure was to book an unregistered nurse for a 11.5 hour shift for a specific patient on a specific ward when a patient was identified with enhanced care needs. The flexibility of an in house team ensures that they can be moved around the hospital covering more areas with less staff to manage and support our high risk patients. It also supports collaborative working with carers and ward staff to consider less restrictive ways of managing patients according to their needs. This includes the use of bay watch which allows patients requiring some additional support and observation, for which 1:1 care is not deemed necessary, and can be cohorted in a bay where ward staff will support this need. The 3 hour shifts are allocated to a ward by the service co-ordinator, using e-roster during the previous day. The team use employee on line to find out their allocations for their 11.5 hour shift to prevent delays in allocations each day. SafeCare is used to inform the wards the time periods for when the support will be in place. If there is a peak in demand and the team are unable to cover the ward then the shift will be put out to NHSP by the service coordinator or duty matron out of hours. As part of the daily staffing meeting the wards that have patients requiring enhanced care are discussed and RAG rated as per safer staffing policy to ensure staff are not moved inappropriately from high risk areas. A patient safety board in the staffing hub is updated daily, to inform the senior Nursing and Midwifery Establishment review April 217 Page 31

32 team of any bay watch wards or high risk patients to enable the senior nurses to make safe staffing decision s. The team are provided with a tailored training program to support the development of the right skills to support this group of patients. In addition the role offers the opportunity for some career progression and development opportunities and as a consequence supports the delivery of a quality service to meet the needs of this vulnerable group of patients. The ENCT has now introduced the following; Implementation of a robust process on managing and controlling the request for a special. Developed a new risk assessment which is completed by the ward staff for any patient that is confused or high risk and may need enhanced care. The risk assessment is ed to the ENCT team. They can also be contacted in an emergency via a bleep system. Introduced daily patient ward rounds by a senior member of the team, where behavioural charts are reviewed, conversation s had with the patient, carers and the staff caring for them. Through this process a decision is made if the 1:1 special is required or if the patient can be stepped down to a less restrictive level of care. Introduced ENCT sticker prompt for the medical notes, prompting consideration of capacity assessments, best interest decisions and DOLs, or the review of the plan. The risk assessment form has been updated to allow clearer classification of individual patient s needs that determine the level of risk. Padlocks on all shifts that go to temporary staffing for specialling Training for matrons and ward managers on utilising their existing staffing resources. For example: Pre-planning staff breaks and establishing a team tag system (Baywatch) to improve patient supervision. Recruitment for enhanced care volunteers to work alongside the team to improve patient experience. Working with carers to provide support, open visiting for the carers and involving them in the care plans. Monthly reports to the nursing workforce strategy group Monthly Audits Findings Since the introduction of this team, the Trust has seen; A reduction in falls A reduction of agency spend, A reduced length of stay A higher standard of care for high risk patients The ENCT team now manages all specialling requests through completion of a risk assessment. The ECNT review all requests and determine what level of risk needs to be managed. The ward Nursing and Midwifery Establishment review April 217 Page 32

33 managers have not been able to book additional duties for since August 216. Table 1 reflects the impact that this change has had on the number of additional duties being added to rosters. Table 1 Quality Outcomes Since the introduction of the ENCT the trust has seen a reduction in Falls. Although this cannot solely be attributed to the ENCT, the team are proactive in ensuring that patients maintain mobility whilst in the hospital environment thus minimising the risk of physical deconditioning which can result in a prolonged length of stay. In conjunction with the ethos of the Mental Capacity Act, the Enhanced Care Team ensure that patients who are unable to maintain a safe environment are effectively supported by applying the least restrictive situation specific management options and interventions, with the aim of reducing a vulnerable individuals risk of falling. There have been 3 reported falls in 18 months where the patient had the enhanced care team allocated to them. Two of these falls were for the same patient who had particularly challenging behaviour. The team have also introduced Bay Watch which has had an impact on falls reduction, and falls with harms. Table 2 shows the comparison of falls from April and May 216 to 217. The Trust is currently 21 falls incidents below the reduction trajectory set for 217/18; it is likely that increased clinical awareness and input from the enhanced care team has had a positive effect on falls prevention. Nursing and Midwifery Establishment review April 217 Page 33

34 Table 2 Table 2 shows the proportion of patients with harm free care at the Trust compared nationally from the NHSI Model Hospital data January 217. This rates ENHT as the 4th best Trust in the country for harm free care. The team are proactive in prevention of deconditioning, promoting independence, maintaining dignity, promoting nutrition and hydration and they also promote these behaviours whilst working in different wards, acting as role models. Table 3 Model Hospital Harm Free Care Data East & North Hertfordshire NHS Trust Nursing and Midwifery Establishment review April 217 Page 34

35 Table 4 demonstrates the reduction in agency spend that has been achieved within the ENCT. Once the team are fully recruited to, the need for agency spend should be eliminated completely on the Lister site. Table 4 Table 5 below reflects the reduction in temporary staffing spend following the increase in establishment within the ENCT. In Q1 in agency spend was 225,322 compared to Q1 in 217 of 83,463. This indicates a cost reduction of 141,859 for the quarter. The cost of the uplift for the team during the same period was 145, with the cost per quarter of 36,25. This early indication suggests the recent modelling of the ENCT service has resulted in a cost reduction for enhanced care of 15,69 for Q1. Table 5 Reduction in Temporary Staff spend Qtr Qtr The uplift in establishment has ensured that once the team is fully established, in August 217, a daily review will be in place seven days a week. The daily review is currently being provided five days a week with support from the matrons over the weekends. Prior to this review patients would have been determined as requiring additional support and a special would have been requested for the whole 11.5hr shift. Patients are now RAG rated to determine the level of care required so that Nursing and Midwifery Establishment review April 217 Page 35

36 appropriate levels of care can be delivered and that staffing resources are used efficiently. The table below indicates the levels of support required. Table 6 Enhanced Care RAG Rating RAG Rating Level of Care Required Assessment process RED Continual 1:1 care required Risk assessment AMBER GREEN 1:1 care required for periods of time but according to individual needs can often be managed on a co-horted basis. Can be managed with ward based care within normal staffing levels of ward /department (Baywatch) Daily ENCT review Behavioural Charts Table 7 indicates the number of patients each day that required enhanced care in May and the colours indicate the level of enhanced care required. In general terms the RED patients require 1:1, the GREEN patients care needs are met with ward based care and the AMBER patients utilise the remainder of the ENCT resource on each shift and is allocated to meet the individual needs of the patients. This can either support co-horting of patients or 1:1 care during certain unsettled times of the day. Table 7 Number of patients per day requiring enhanced care May 217 The staffing model that has been implemented supports the requirements of the minimum workload (12 patients approximately dependant on clinical needs). However when there are peaks in requirements and / or the number of patients requiring continual 1:1 support increases, the substantive team are not large enough to meet the requirements or to maintain the safety of these Nursing and Midwifery Establishment review April 217 Page 36