NLG(16)213 DATE OF MEETING 31 May 2016 REPORT FOR Trust Board of Directors Part A REPORT FROM Tara Filby, Chief Nurse CONTACT OFFICER Tara Filby, Chief Nurse SUBJECT Update to the Board relating to nursing, midwifery and care staffing capacity and capability BACKGROUND DOCUMENT (IF ANY) National Quality Board (NQB) report How to ensure the right people, with the right skills, are in the right place at right time 2013 (NHS England). REPORT PREVIOUSLY CONSIDERED BY & DATE(S) EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF) HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS? HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS? ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS? IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED? ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF? WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED? This is the monthly report outlining those wards where staffing capacity and capability fell short of what was planned and any risks were mitigated. No No No No No WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE? THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED N/A ACTION REQUIRED BY THE BOARD The Trust Board is asked to note the report and support any further action required NLG(16)213 Page 1
Report From: Tara Filby, Chief Nurse Date: May 2016 Subject: Purpose: Expectations relating to nursing, midwifery and care staffing capacity and capability This report provides an overview of nursing and midwifery staffing and advises the Board of those wards where staffing capacity and capability fell short of what was planned and any mitigation. 1.1 Background This report will advise the Trust Board of those wards where staffing capacity and capability fell short of what was planned, the reason why and any impact on quality and the action taken to mitigate any risk in staffing from 1 April to 30 April 2016. The organisation s expectations around safe nurse staffing have been defined as follows: 1 RN to 8 patients (minimum) for standard acuity wards on days 2 nurses on each shift as a minimum on inpatient wards Establishments based on a headroom allowance of 23.8% for sickness, absence, training and leave is built into the plan The Trust website publishes all ward by ward data on planned versus actual numbers of staff by nurse/midwife and health care staff by day duty and night duty. A summary of this fill rate can be found in appendix A of this report. NHS England has requested exception reporting around those areas where compliance around expected hour s vs actual hours for nurses (aggregated monthly data) are less than 80%. This report provides details of where compliance was less than 85%, our Trust internal target (Amber rated) along with those areas where compliance was less than 80%, national target (Red rated) - 7 from 38 wards fall into this red rated category, an improvement in month. To support the achievement of safe staffing and to take account of the daily fluctuating patient care needs there is a daily, ward by ward, review of staffing levels. It is at these group meetings that senior nurse decisions and management of risk is made to ensure patient safety and appropriate skill mix of to un nurses is facilitated. The WebV clinical system is being used by Operational teams to support the allocation/redeployment of resources according to patient acuity and dependency. NLG(16)213 Page 2
2.0 Deviations in staffing capacity and capability The table below demonstrates the site level fill rates illustrating that the planned establishments were maintained on average across the sites. Day Night Day Night Overall Site Fill rate - nurses/midwives Fill rate - care staff Fill rate - nurses/midwives Fill rate - care staff Average Nurse fill rate Total average fill rate Grimsby 89.8% 105.3% 95.5% 105.5% 93.3% 98.9% 95.4% Goole 86.8% 106.6% 95.9% 106.5% 95.2% 99.4% 96.8% Scunthorpe 88.0% 103.8% 95.9% 93.3% 95.2% 96.7% 95.7% The Trust Overall % fill rates are calculated using the combined total raw data from the 3 hospital sites. These show overall that shifts are filled above the national 80% fill rate. Site Fill rate - nurses/midwives Day Night Day Night Overall Fill rate - Fill rate Fill rate Average Nurse fill rate - care staff - care staff nurses/midwives Total average fill rate Trust Overall 89.8% 103.8% 95.7% 105.8% 95.9% 99.1% 97.1% Overall the Trust position in terms of fill rate has continued in month however this has been achieved by continued reliance on temporary staff, e.g. bank and agency (see Appendix A). It is pleasing to see that for the month of April there continued to be a nil expenditure on agency HCA shifts. The Trust has also not filled any of the roster gaps with agency nurses from off framework agencies since 29 February 2016. In response to a request from the Trust Board, detailed information is included below in relation to trends in these fill rates from June 2015 April 2016. Overall fill rate 100.00% 95.00% 90.00% 85.00% 80.00% overall GDH Linear (overall) 75.00% This shows a significant improvement in Goole which reflects a positive change from when the roster template was more closely matched to activity however overall shows a fairly static picture. NLG(16)213 Page 3
Breaking the fill rate down further into RN/HCA shifts on day/night duty provides additional insight into fill rates locally: RN fill rate on days 100.00% 95.00% 90.00% 85.00% 80.00% GDH Trust Overall Linear (Trust Overall) 75.00% This shows an overall deteriorating position in relation to filling day shifts with nurses. This correlates with a positive fill rate position for HCAs, where posts have been easier to recruit to: HCA fill rate on days 115.00% 110.00% 105.00% 100.00% 95.00% 90.00% 85.00% 80.00% 75.00% GDH Trust Overall Linear (Trust Overall) 70.00% 65.00% NLG(16)213 Page 4
The night fill rate position is more stable and this reflects the commitment of senior nursing management teams to prioritise the night shift for both RNs and HCAs as there is less support available from other staff groups out of hours: RN fill rate on nights 100.00% 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% 84.00% GDH Trust Overall Linear (Trust Overall) 82.00% 80.00% HCA fill rate nights 125.00% 115.00% 105.00% 95.00% 85.00% GDH Trust Overall Linear (Trust Overall) 75.00% 65.00% NLG(16)213 Page 5
The fill rate data provides an overview of the position however it does not provide an indication of how effectively the actual filled shifts meet the needs of patients in terms of matching acuity and dependency. Work is underway to present data in a meaningful way, i.e. care hours per patient day, which will be reported nationally from June 2016 and will therefore be included in this report. Work is on-going in conjunction with the Roster lead to present some evidence of whether the planned shift requirement and actual fill rate met the demand in terms of patient need. The Safer Care Nursing Tool has been used for many years within NLaG and other Trusts to retrospectively review the acuity and dependency of patients in our care. Senior nurses in NLaG now use data from the SNCT to review establishments and coordinate the effective deployment of staff. Front-line nurses assess each patient at least daily, preferably each shift and attribute a score based on the SNCT model (category 0, 1a, 1b or 2). This information is input into the WebV solution and viewed by Operational Matrons as an acuity score. The detail is then pulled from the system by the Roster team who can produce graphs to compare the number of hours required to care for the patients (based on their needs) with the planned hours on the agreed roster template. Data is then added that shows the actual hours worked and broken down into substantive staff, bank and agency. An example of this is given below: This graph shows that on 3 early shifts in the month, staffing numbers did not meet the planned template. There is regular reliance over the month on bank and agency staff to meet the planned numbers. There is a fluctuation in the requirement based on the SNCT categories of patients but most of the month, the requirement exceeded the planned hours. Decisions are made on a daily basis to best match staffing to patient need and this acuity tool does assist the operational teams with effective staff deployment. The nursing dashboard outcomes, falls and pressure ulcer data are provided in Appendix A. This provides a level of assurance in relation to the quality impact in association with nurse staffing levels. None of the dashboards are RAG rated red. It is pleasing to see significant improvement within the paediatric dashboards this month. NLG(16)213 Page 6
3.0 Reasons for the gap The following table summarises the gap and the action taken to address the gaps in fill rate for each of the red rated exception wards in order to ensure the wards remain safe. <80% compliance was reported in 7 wards: Ward Gap Action taken Is it safe? NICU Reduction in RN & HCA on day and night duty Long term & short term sickness are contributing factors. Shifts have been supported by the community team. NICU staff have also supported Rainforest when cot occupancy falls - redeployment was facilitated and both areas safe. Stroke Unit Reduction in RN on day duty 4 vacancies. 3 pre-reg. nurses waiting PIN needing support. No major concerns re patient safety. Action plan in place and Matron working hours on the ward to support new staff. Staffing is reviewed daily and staff redeployed from other areas in accordance with acuity. Support also received from HCA pool/response. GOOLE Ward 6 Reduction in HCA on day duty Fill rate reflects low acuity and occupancy. Also the HCA on the 10-6 comes from ward 7 establishment and therefore would not be reflected in the establishment or the numbers. Disney Reduction in RN on day duty Gaps are due to sickness. Staff redeployed between areas and sites as acuity and dependency dictates. Ward 17 Reduction in RN on day duty Vacancies being proactively managed, e.g. HCA backfill cover as appropriate. Daily review by Matron. Staff redeployed from other areas to cover and bank and agency staff used. Ward 17 review patient dependency and acuity - have 23 beds so choose to have 3 RN s on the late still giving a ratio of 1 RN to 8 patients to prioritise higher risk early and night shift. Ward 18 Reduction in RN on day duty Vacancies being proactively managed, e.g. HCA backfill cover as appropriate. Daily review by Matron. Sister escalates when additional support is required. Staff redeployed from other areas to cover. Use of bank and agency employed. Have 14 inpatient beds so are covering the E with 3 RNS and having 2RNs on the late which still gives a ratio of 1:7 for the late. Ward 23 Reduction in RN on day duty Vacancies being proactively managed, e.g. HCA backfill cover as appropriate. Staff nurse post filled in May so fill rate should improve. Daily review by Matron. Sister escalates when additional support is required. Staff redeployed from other areas to cover. action plan in place due to avoidable pressure ulcers in month support from both the Quality Matron and Operational Matron to the new Ward Sister is in place It is evident that where it is safe to do so, HCA shifts are used to backfill shortages in RN shifts on the roster. This correlates with an overfill rate on the template as evidenced in Appendix A, e.g. in several of the red rated areas. NLG(16)213 Page 7
The rationale for apparent overfill rates in other areas includes: Ward name Average fill rate - nurses/midwives Average fill rate - care staff Average fill rate - nurses/midwives Average fill rate - care staff LAUREL WARD 98.1% 127.7% 100.0% 146.5% Local group decision - agreed to go over establishment with HCA s due to the high acuity/dependency of medical outliers on the ward. This was deemed appropriate as existing establishment would not cover this level of patient need. The issue of medical outliers on Laurel was discussed in detail at QPEC and NMAF this month with additional actions being taken in support of both patients and nursing staff, e.g. review of appropriate transfers B2 100.9% 97.6% 98.8% 133.3% Additional HCAs requested on nights due to requirement for 1:1 care needs of high risk patients. B3 89.5% 135.0% 100.1% 121.5% The fill rate is due to high acuity and occupancy, the average fill for RN was reduced due to placing a staff member on supernumerary shifts and band 4 being in HCA shifts also. Wards that have not flagged as Red but are a cause for concern due to the low % fill rate by substantive nurses include: B4 Ward 22 Ward 24 Priority focus has been given to these areas for booking temporary staff due to the need for continuity of care. They also feature within the top 10 on the ward risk profile as a focus for the recruitment of experienced nurses. 4.0 Summary Each ward is reviewed daily by the operational matrons and Associate Chief Nurses and any redeployment of staff is undertaken on a shift by shift basis. The operational matrons plan the next day staffing requirements by reviewing the acuity and dependency of the wards they are responsible for and in conjunction with the ward sister/charge nurse. An additional weekly meeting is being held to proactively look ahead at roster shortages and consider mitigation including block booking of staff from framework agencies The skill mix of the nursing workforce is taken into account daily especially in light of recent successful recruitment initiatives locally and overseas. We make conscious decisions to move nurses by ward or within their own ward according to competency and skills Where we have vacancies in ward areas we are actively recruiting to these posts and this is monitored by the operational groups and through a Nurse staffing group which meets weekly. A ward risk profile is regularly updated and used in accordance with targeted recruitment activity to suit the needs of each ward Where we have fluctuations in activity we flex the nursing staff to patient need and support other ward areas. Associate Chief Nurses and their operational matrons meet every Ward Sister/Charge Nurse across their areas to ensure that all staffing is in line with rosters and agreed budgets. Nursing dashboard data is monitored by exception at NMAF. The 2016 review of nursing establishments is nearing completion and a more detailed report will be presented at a future Trust Board meeting 5.0 Conclusions The Board are asked to note the report and support any further action required. NLG(16)213 Page 8
Appendix A Fill rates Nursing, Midwifery and Care staff Ward name Average fill rate - nurses/mi dwives Day Night Day Night Number of Avoidable Falls Average fill rate - care staff Average fill rate - nurses/mi dwives Average fill rate - care staff Average fill rate - substantive midwives/nur ses Average fill rate Substantive care staff Average fill rate substantive midwives/nur ses Average fill rate substanti ve care staff AMETHYST & D1 89.6% 102.9% 101.4% 103.2% 86.3% 89.7% 86.3% 75.06% Blueberry /Holly 101.8% 99.6% 101.3% 99.8% 97.7% 96.6% 94.4% 96.63% C1 KENDALL 97.8% 91.9% 95.2% 91.8% 76.6% 71.9% 46.8% 60.00% CORONARY CARE UNIT 105.5% 106.1% 93.7% - 85.7% 92.4% 68.1% - Honeysuckle/ Jasmine 98.5% 99.2% 97.8% 100.4% 96.5% 93.5% 78.1% 93.77% ITU 95.2% 100.3% 97.2% - 87.9% 100.3% 91.7% - LAUREL WARD 98.1% 127.7% 100.0% 146.5% 92.2% 86.4% 86.7% 86.67% NICU 77.9% 76.7% 73.3% 63.3% 73.4% 73.3% 69.3% 63.33% Rainforest 90.5% 93.3% 92.2% 116.7% 77.2% 86.7% 85.6% 103.33% STROKE UNIT 73.7% 125.2% 98.1% 86.6% 70.9% 124.4% 50.0% 74.65% WARD B2 SAU 100.9% 97.6% 98.8% 133.3% 96.2% 93.8% 87.8% 113.33% WARD B3 89.5% 135.0% 100.1% 121.5% 76.1% 133.3% 78.3% 103.55% WARD B4 84.4% 116.4% 100.3% 107.0% 39.9% 108.6% 38.5% 83.41% WARD B6/B7 94.0% 103.0% 99.2% 101.4% 85.7% 98.6% 89.2% 96.97% WARD C1 HOLLES 87.6% 101.6% 98.3% 91.1% 79.7% 86.8% 75.8% 84.44% WARD C5 91.6% 94.9% 95.0% 112.5% 85.4% 87.1% 86.7% 101.67% WARD C6 89.0% 94.4% 98.5% 101.5% 82.1% 73.3% 71.8% 79.16% CCU 85.5% 112.5% 98.5% 100.0% 75.9% 99.6% 91.8% 56.67% Disney 68.2% 84.8% 98.9% 100.0% 67.3% 79.4% 98.9% 96.67% ITU 96.3% 90.5% 96.2% - 93.3% 90.5% 88.2% - NICU 82.7% 97.3% 88.0% 96.7% 76.4% 97.3% 85.6% 90.00% GYNAECOLOGY 90.6% 107.1% 99.7% - WARD 68.8% 104.1% 50.1% - SSRU 91.5% 105.8% 95.7% 98.5% 86.5% 99.6% 89.7% 94.70% WARD 10/11 98.7% 97.9% 99.6% 100.0% 97.9% 96.7% 77.4% 98.33% WARD 16 84.9% 113.4% 95.8% 98.8% 64.9% 111.2% 63.3% 92.65% WARD 17 72.3% 120.8% 100.0% 98.1% 53.4% 118.5% 83.3% 83.33% WARD 18 79.1% 114.9% 102.3% 98.3% 70.8% 99.5% 62.6% 71.67% Number of Avoidable PU Nursing Dashboard % 0 0 95.9% 0 0 97.6%/97.6% 0 0 92.6% 0 0 95.3% 0 0 100%/100% 0 0 100% 0 0 88.9% 0 0 99.1% 0 0 95.5% 0 0 98.5% 0 0 96.5% 0 0 97.6% 0 0 92.9% 0 0 87.9%/91.8% 0 0 98.8% 0 0 95.1% 0 0 91.2% 0 0 97.4% 0 0 100.0% 0 0 100.0% 0 0 100.0% 0 0 96.7% 0 0 98.2% 0 0 96.7%/97.7% 0 0 97.1% 0 3 92.2% 0 0 96.7% 5
WARD 2 WARD 22 WARD 23 WARD 24 WARD 25 WARD 26 WARD 28 WARD 6 WARD 3 90.0% 119.8% 99.1% 110.0% 74.3% 100.4% 58.0% 86.67% 104.4% 105.1% 95.5% 112.0% 46.4% 96.9% 45.6% 86.67% 76.4% 117.6% 100.0% 99.8% 68.9% 113.7% 53.3% 93.18% 86.2% 97.8% 99.9% 97.8% 52.7% 77.1% 50.0% 88.89% 94.8% 112.1% 100.0% 113.3% 81.7% 104.8% 51.7% 105.00% 80.6% 100.2% 82.6% 99.4% 64.7% 100.2% 72.8% 99.42% 97.4% 99.4% 100.0% 105.0% 87.0% 98.5% 90.0% 101.67% 89.6% 77.4% 86.7% - 89.6% 69.9% 86.7% - 89.3% 103.8% 98.3% 93.3% 89.3% 103.8% 98.3% 93.33% 0 0 97.4% 0 1 92.3% 0 0 97.4% 0 0 97.4% 0 0 97.9% 0 0 100.0% 0 0 99.5% 0 0 99.2% 0 0 99.6% Fill rate key <85% <80% Nursing Dashboard Key Calculated Thresholds Over 95% Over 85% Under 85% 6