Welsh Risk Pool Services

Welsh Risk Pool Services Composite Report of the Themed Review on Nursing Care Provision 2015-2016 Status: Final

Contents Executive Summary... 2 Overall Arrangements... 3 Record Keeping... 4 Overarching comments... 4 Recommendations... 5 1. Introduction... 6 2. The Themed review process... 6 3. Review of nursing documentation... 7 4. Interview process... 7 5. Detailed findings and recommendations from the review.... 7 6 Good practice identified... 12 7. Summary... 13 Page 1

Executive Summary The WRPS assessments have recently focussed on specialities considered to be at high risk of litigation and these have confirmed that organisations are pro-active in developing procedures and protocols in relation to recognised good practice. However, the operational implementation is more challenging and the claims indicate that often there are weaknesses in the fundamentals of care provided. These include communication, record keeping, undertaking risk assessment and acting on observations. Furthermore, the clinical audit and performance management arrangements are not necessarily well developed to provide management and governance assurance or highlight deviations from expected practice. The WRP Committee confirmed the approach for 2015/2016 that focussed on the essentials of care which are relevant to claims. This included a review within each Health Board (on designated medical and trauma and orthopaedic wards) of patient records and staff interviews to ascertain compliance with good practice in relation to: Risk assessments relevant to the patient (e.g. falls, continence, nutritional status) and evidence of compliance Compliance with skin care bundles Management of infection and sepsis Patient monitoring and escalation Evidence that test results have been acted upon General record keeping Staffing levels and acuity Availability and use of bariatric equipment Training provision of staff Compliance with incident reporting requirements Clinical audit arrangements for risk assessments, record keeping, essential nursing care. Action plans and follow up arrangements The WRPS review incorporated a study of five sets of nursing notes per each of the two Assessors. One Assessor was allocated to Medical Wards, the other to Trauma and Orthopaedic Wards. The Assessors also reviewed ward acuity, medical review of outlier patients, staffing levels and the use of bank and agency staff. Key findings from the themed reviews are highlighted below, with links to the main body of the report. Page 2

Overall Arrangements Nurse staffing levels were of concern at all the wards visited throughout the reviews. Staff interviewed reported that their ability to provide appropriate care was often compromised. Most areas carry vacancies and only one organisation had managed to improve nurse recruitment significantly. (5a, 5.1g, 5.1h, 5.1i, 5.1k) Statutory and mandatory training has been adversely impacted on by ward acuity and low staffing numbers as staff release becomes problematic. (5b) Recruitment drives are taking place abroad and in the UK and are targeting Universities in Wales to recruit nurses as they qualify. (5c) Leadership skills at ward management level were apparent from visits to a number of sites.(5d) Proactive discharge planning was evident on the wards visited but staff interviewed reported that ensuring appropriate community care or placement can be problematic. (5e) For patients outlying to wards in other specialities there are either systems in place to assign responsibility for ensuring regular medical review or the patients chosen for transfer are already medically fit for discharge and awaiting completion of arrangements. (5f) Bed availability continues to be a concern at operational and senior management levels. Escalation processes are in place but the pressure on hospitals has been such that they are regularly in high intensity status, which impacts significantly on bed waits and regularly leads to cancellations of elective surgical procedures. (5g, 5.2h, 5.2m ) Where Ortho-geriatric Consultants support Orthopaedic colleagues in providing care for elderly patients with conditions unrelated to their orthopaedic problem it was reported that discharge can be more timely and that the service has increased nursing knowledge and skills base. Physiotherapy and Occupational Therapy staff dedicated to the wards was also cited as helping to ensure timely discharge. (5.2f, 5.2i) Patients are informed about their orthopaedic surgery via the Joint School process, which helps to manage expectations and ensure that patients have information on the likely recovery and discharge timescales. (5.2j) Patient meals are served on the ward from heated trolleys, improving patients choice, portion control and intake monitoring. Provision with assistance to eat was noted at the reviews. (5.2g) Page 3

Record Keeping Nursing accountability sheets were included in the front of patient records that include the printed name and signature of all staff who make entries in the record. Nursing records are kept as standalone documents or incorporated with medical notes. In either case correlation between management plans could be seen. Where documentation and filing was standardised entries were clear and neatly presented. (5h, 5.1f, 5.2a, 5.2c) In the main nursing records were up to date but in several locations gaps in chronology were noted. Recommendations were made in respect of monitoring and action. (5.1b, 5.2d) Specific condition pathways were used and standards of completion varied. Duplication was noted where several pathways were used concurrently and this made chronology of care provision difficult to follow. Recommendations were made in these cases. (5.1c) Record keeping audits take place on most wards (5.1d, 5.1e, 5.2k) Risk assessments were completed and informed care plans.(5.1b, 5.2b) Overarching comments The wards were without exception extremely busy on the days of the site visits, however it could be seen that the patients were being well cared for. (5.1a, 5.2e) Page 4

Recommendations (5.3) It has been recommended that the organisations: Continue to expedite nurse recruitment as a priority. Consider the acuity and dependency levels of patients when establishing staffing establishment numbers. Ensure risk assessments are completed for any patients being nursed in the wards on trolleys and that these correlate to nursing care plans. Continue to regularly audit record keeping standards, the handover process and care provision to ensure that shortfalls have been addressed. Report any concerns with temporary nursing staff promptly to the Nursing Agency. That any concerns expressed in respect of safe discharge are taken seriously. WRPS have had a number of claims where unsafe discharge has led to successful litigation and discussions were held at the site visits in respect of these. Page 5

1. Introduction This report sets out the scope and findings of the Welsh Risk Pool Services Themed review of nursing care provision on medical and trauma and orthopaedic wards that was undertaken between the October 2015 and April 2016. 2. The Themed review process Previous WRPS reviews of the high risk clinical areas identified that NHS organisations in Wales can demonstrate compliance with documentary requirements relating to policy and strategy. However, there were significant pressures on implementation and only partial compliance was achieved in respect of training and clinical audit with evidence of pressures on staffing levels. The interview process undertaken in previous years highlighted further weaknesses in implementation of policy. These weaknesses align with recurrent themes identified within claims submitted for reimbursement to WRPS. Given the relevance to current claims, the Welsh Risk Pool Committee (WRPC) and the Chief Executives Peer Review Group have confirmed their commitment to reviewing the high risk clinical areas. The current arrangement includes a review of key documentation and supporting evidence with interviews with a range of staff to gauge implementation. The process places a greater emphasis on the themes that commonly recur in claims. These themes include: Failure to provide adequate nutrition/hydration Failure to appropriately monitor vital signs Failure to recognise patients deteriorating conditions Failure to act on abnormal results of diagnostic investigations Failure to provide appropriate training Delay in diagnosis and/or treatment Weakness in obtaining informed consent to treatment Substandard surgical procedures The process included Pre site confirmation of the areas to be reviewed by the Assessors and confirmation of the dates of assessments A site visit by the WRPS Clinical Assessors to review nursing care provision and record keeping standards Interviews with relevant staff as appropriate to the area under assessment to evaluate compliance with the related procedures. Conclusion of findings and the issue of a report for each speciality for each Health Board with key findings and recommendations. An all Wales composite report will be issued to Chief Executives and the Welsh Government upon completion of all reviews. Page 6

The approach outlined above was approved by the WRPC and consultation took place with the Medical Directors and Directors of Nursing. A series of awareness raising sessions to introduce the updated approach and raise awareness of the cost of claims to NHS Wales has been undertaken. 3. Review of nursing documentation The WRPS review incorporated a study of five sets of nursing notes per each of the two Assessors. One Assessor was allocated to Medical Wards, the other to Trauma and Orthopaedic Wards. The Assessors also reviewed ward acuity, medical review of outlier patients, staffing levels and the use of bank and agency staff. 4. Interview process Interviews with ward staff were conducted. Staff were selected by senior nursing staff on the ward and the Assessors discussed systems and process related to risk assessment, monitoring of vital signs and escalation of any deterioration identified, workload and staffing arrangements, review of patients outlying to other speciality wards, discharge planning and training provision. 5. Detailed findings and recommendations from the review. The detailed review findings have been included below in sections relevant to the wards visited. Recommendations were provided in each individual report and a resume of these is included below. It is important to note, however, that at most sites and on wards: a) Staffing levels were a concern for all the staff interviewed. It was reported that staffing establishment figures in most areas carry vacancies and do not equate with acuity and patient dependency levels. Staff interviewed regularly stated they felt the staffing levels were at unsafe levels which could compromise patient care. In only one organisation was it apparent that there is corporate realisation that numbers need to increase further to meet safer staffing levels. This same organisation was also the only one where wards visited had a complement of staff that equated to establishment figures (Aneurin Bevan UHB). b) Statutory and mandatory training has been adversely impacted upon in all the organisations affected by high ward acuity and low staffing levels. Only one organisation was seen to have made significant improvements to compliance levels but others are beginning to make progress in training provision after targeted improvements were given corporate focus. Where manual handling trainers are ward based training and competency assessments are more up to date. E-learning has reportedly increased compliance with mandatory subjects. Page 7

c) Recruitment drives are in place within most Health Boards and initiatives such as Open Days have taken place in an attempt to reduce the number of nursing vacancies that presently exist. The recruitment drives also target Universities with the aim that nurses in training can go straight into a substantive post on qualifying. This may affect skill mix in forthcoming years. d) In some wards it was apparent there is excellent leadership and staff feel supported and valued as members of each of the team. Where this was noted it was highlighted within the individual organisation s report. There were no occasions where poor leadership was observed but regularly the senior nursing staff on the wards have difficulty in balancing management duties with their clinical workload. On one trauma and orthopaedic ward it was apparent that the high acuity and workload was particularly stressful for the ward manager. Patients were being nursed on trolleys in the ward and more admissions arriving despite this over capacity working. Recommendations were made to the organisation in respect of providing support and escalation procedures. e) Proactive discharge planning was evident from the site visits. Multidisciplinary involvement takes place and every effort is made to ensure timely discharge. Ensuring safe discharge and appropriate follow up care or placement in the community can be problematic and residential places limited. Some staff interviewed were concerned that discharge can be significantly delayed where the patient s relatives wish to choose a particular residential home or prefer the patient to remain in hospital. It has been recommended that the frequency of this delay is discerned and a process put in place to manage family expectations. f) Where patients outlie to wards in other specialities there are systems in place in all but one ward visited to ensure regular medical review takes place. These systems differ but in all responsibility for review and coordination of care are assigned at either medical or nursing level. On the ward where regular review is more problematic the patients who outlie are chosen carefully and only those who are fit for discharge are transferred. g) Bed availability is a concern at senior management and operational levels. There are escalation and bed management processes that aim to identify such problems at an early stage and expedite solutions. However, the pressure on the hospitals has been such that the capacity status is regularly at level four, which impacts significantly on bed waits and regularly leads to cancellations of elective procedures. h) Nursing accountability sheets were included at the front of patient records that include the printed name and signature of all staff who make entries into the record. Page 8

5.1 General Medicine Wards a) The wards were without exception extremely busy on the days of the site visits; however the patients on these wards looked well cared for. Ward capacity varied across sites between 21 and 31 beds and generally fully occupied. In some hospitals patients were being nursed on trolleys in the wards, which apparently happens on a regular basis. b) In the main nursing records were up to date, including completion of risk assessment but in several locations it was noted that there were gaps in chronology and in some cases blank lines that had not been struck through were present. It was pointed out that these are transgressions against clinicians codes of conduct and recommendations were made in respect of monitoring and action. c) Specific condition pathways were used and standards of completion varied. In some cases duplication of care records was noted as several pathways were used concurrently and this made the chronology of care difficult to follow. It was also noted at a number of organisations that some pages were insecure within the files and if they became misplaced episodes of care could not be established, which would leave the organisation vulnerable in any cases of litigation. In these cases recommendations for action have been made. d) Record keeping audits of nurse documentation are being undertaken in all but one medical ward visited (where recommendations into adopting the practice were made). Several of these audits have identified that there is a need for improvement. Where this need has been evident action to improve standards has been put in place. e) Handover sheets were not always completed and recommendations made to several organisations in this respect. f) Storage of nursing notes varies across the organisations; some are incorporated into the medical notes, others are standalone. g) Staffing levels were a concern for all the staff interviewed, on all sites. It was reported at all sites that staffing establishment figures do not equate with acuity and patient dependency levels. Due to the nature of the patients being cared for on the medical wards visited, their behaviour could be unpredictable e.g. patients with alcohol dependency suffering withdrawal and staff are regularly faced with challenging and aggressive behaviour. Some confused patients or patient susceptible to falls require one to one care, which can be difficult to provide at times. Bank and agency staff are regularly utilised, however it is not always possible to cover every shift especially Page 9

when short term sickness occurs. The dependency on nursing agency staff was very high in several organisations, with some such temporary staff covering each shift. This situation was also noted on the trauma and orthopaedic wards. h) Several nurses interviewed cited times when they have been distressed at their inability to provide the care required and feel professionally vulnerable as a result. It was stated that there is often the need to stay late after shift completion in order to cover shortfalls in numbers and to manage the priority work. This then can eventually lead to increased sickness levels and it was noted that sickness levels were high in the worst staffed areas. i) It was reported that there are occasions when qualified nurses have to rely on Health Care Support workers assessing the skin integrity of patients as they did not have capacity to review their patients on a daily basis. j) Other difficulties reported were that patients requiring assistance with feeding had to wait to be assisted with their meals. This can result in them being fed cold food. It was noted, however, that in the majority of patient surveys completed, patients have indicated that they were satisfied with the care provided. k) Staff are widely encouraged to report any incidents via the Datix reporting systems. 5.2 Trauma and Orthopaedic Wards. a) Nursing and medical notes are kept either together or as separate folders. However, correlation between the management plans could be seen in each type of practice. b) Risk assessments were generally completed, with the core evaluations informing care plans. Additional assessments were completed where the core evaluations highlighted the need. Nursing notes refered to action taken in respect of care planning that result from the assessments. c) In areas where nursing documentation and presentation was standardised across the sites entries were clear and legible and the folders were neatly organised with laminated dividers. This made confirmation of risk assessment, care plans and care delivery easily recognised. Care plans and entries were complete and contained no gaps. Where the manner of presentation was less coherent recommendations were made and documentation systems from organisations who had a high standard referenced. Page 10

d) Few gaps were identified in the risk assessments, patient monitoring charts or nursing notes. Where any gaps were noted these were pointed out at the time of the assessment and included in the individual reports with clear recommendations made. e) The wards visited were all extremely busy. In many cases it was plain to see that the workload was almost unmanageable. A number of patients had cognitive impairment and/or multiple co-morbidities. Staff were constantly interrupted by telephone enquiries, doctors wanting assistance and new patients needing attention. However, in all the wards the Assessor noted that care was being delivered in an empathetic and professional manner. f) In some organisations Ortho-geriatricians support their orthopaedic colleagues on the trauma wards and manage care of patients with comorbidity conditions that sit alongside their orthopaedic problems. Staff interviewed reported that this medical input has increased the knowledge and skills basis of the nursing staff on the wards and has also aided more timely discharge. g) In most hospitals patients meals are served from heated trolleys, which allows for patient choice, portion control and intake monitoring. Provision of assistance with eating could be seen taking place during the site visits to the orthopaedic wards. h) In a number of sites it was noted on the day of the visits that elective operations had been cancelled due to the number of trauma cases presenting, theatre problems and/or postoperative bed availability i) Most of the trauma and orthopaedic wards visited had dedicated physiotherapists and occupational therapists. Staff interviewed reported that this is a vital service that aids timely recovery, recuperation and discharge. j) The Joint School process is implemented in all the areas visited. This process aims to prepare the patients for their operation, their likely recuperation period and how they will be expected to contribute to their recovery. Sessions are provided across the health boards. Staff interviewed were confident that the process makes an appreciable difference to timely discharge. k) Staffing was a significant problem on the wards visited at all the health boards. In many cases providing safe staffing numbers depended on the flexibility of part time staff and the willingness of full time staff to work extra shifts. The ward staffing levels were in the main less than establishment figures. In only one organisation were establishment figures better by comparison but this had followed a stringent effort at recruitment over the previous two years and there was the realisation that further recruitment must take place. Generic recruitment is under Page 11

way in many organisations, with regular recruiting open days. These aim to attract new staff, including those who are currently in their second year of nurse training. In one organisation it was demonstrated that recruitment and HR staff attend the open days and attendees who are successfully recruited can have their identification documents scrutinised and recorded and criminal record checks applied for on the same day. This then shortens the recruitment process significantly. l) Record keeping audits and basic nursing care provision is audited and results fed back to staff. Results were satisfactory in most cases and where shortfalls were identified action has been taken to improve practice. m) Bed availability is a key issue at all the acute hospitals. Staff interviewed reported that there is often pressure to discharge a patient who may be medically fit but has little care provision at home. There is reportedly no step down provision for convalescence or for delays in care package provision. 5.3 Recommendations: Specific recommendations have been made to the individual health boards where shortfalls were identified but generically it has been recommended that the organisations all: Continue to expedite nurse recruitment as a priority. Consider the acuity and dependency levels of patients when establishing staffing establishment numbers. Ensure risk assessments are completed for any patients being nursed in the ward on trolleys. Continue to regularly audit record keeping standards, the handover process and care provision to ensure that shortfalls have been addressed. That any concerns expressed in respect of safe discharge are taken seriously. WRPS have had a number of claims where unsafe discharge has led to successful litigation. 6 Good practice identified Recruitment and Human Resources staff attend the open days and attendees who are successfully recruited can have their identification documents scrutinised and recorded and criminal record checks applied for on the same day. (ABMU) Nurse and Therapies Led Unit for patients who are medically fit for discharge (Aneurin Bevan UHB) Page 12

Nurse identification stamp used in Ysbyty Glan Clwyd Hospital (BCUHB) The documented weekend plan of care utilised on the medical ward at University Hospital Llandough that is reported to be working well in continuing treatment for patients in the out of hours period.( Cardiff and Vale UHB) Coloured zimmer frames + painting toilet doors yellow to help patients with dementia. (Cardiff and Vale UHB) Work ongoing in house and with outside agencies and charities to consolidate the discharge process and help ensure that patients are discharged to suitable environments with appropriate care provision.(cwm Taf UHB) The password system in place for when relatives telephone the trauma and orthopaedic ward requesting information or updates on their relative. (Cwm Taf UHB) The Ortho-geriatric Consultant post that is ward based rather than shared care. (Hywel Dda UHB) The style of the newly introduced Nursing Assessment documentation in the form of a secure booklet and incorporates all patient risk assessments. (Powys thb) 7. Summary Nurse staffing levels are of concern at all organisations reviewed. Most areas carry vacancies. Statutory and mandatory training has been adversely impacted by staffing levels and high ward acuity. Recruitment drives are taking place in the UK and abroad and are targeting Welsh Universities to recruit nurses as they qualify. This may have an impact on skill mix in the forthcoming years. Leadership skills at ward management level were apparent on several of the sites visited. Processes are in place to manage appropriate medical review of patients outlying in other speciality wards. All wards visited were seen to be very busy and it was apparent that bed availability continues to be a concern at operational and senior management levels. Record keeping standards were generally satisfactory, although some gaps and duplication were noted that impedes a chronological account of care delivery. Risk assessments were completed and inform care plans. Audits take place and where shortfalls have been identified action is taken to improve standards. Specific recommendations have been made to the individual health boards where shortfalls were identified. Welsh Risk Pool Services would like to thank the staff involved in organising and the completion of the themed reviews for their help and assistance. Page 13