Quality Governance and Risk Committee Safer Staffing Report January 2018

Introduction Quality Governance and Risk Committee Safer Staffing Report January 2018 The Safe Staffing initiative is part of the NHS response to the Frances Report which called for greater openness and transparency in the health service. From April 2014, it became a national requirement for all Trusts to Provide monthly workforce reporting to the Trust Board Undertake six monthly establishment reviews are completed Display daily planned versus actual staffing numbers in the clinical areas Publish workforce data on the trust s public facing website Provide monthly updates to Trust Board and/or delegated committee on the status within the inpatient areas This report provides an overview for January 2018 Issues identified for January 2018 Ward 12 highlighted to matron and senior management from CTL about the staffing issues due to sickness through the month of January Ward 9 also recorded a number of Datix incident related to staffing in January including 4 incidents of agency staff who did not arrive and 1 concerns with tracheostomy care. CCDU and Ward 8 both reported 2 incidents where agency staff did not attend. Ward 9 reported a number of increased patient dependency challenges - 4 Tracheostomy patients.4 patients on 1:1 supervision on a 24 hours basis, 3 patients on 15 min checks and 2 patients showing challenging behaviour including a Substance A grade user One Bariatric patient remains on ward 8. The patient needs 2-3 staff for care provisions hence 1 additional HCA had to be booked for all shifts to support patient care needs. Also, 1 patient needs 1:1 supervision on all shifts. 12 patients needed escort provision for Out-patient Clinic appointments. There were 4 units showing amber compliance for ECIs in January - C27, Ward 9, Perrytrees and Willow House There were no red flag alerts reported in January There were 5 Serious incident recorded in January, falls with fracture on ward 5, Perrytrees and C27 and Flu outbreaks on Ward 6 and Willow House staffing levels are being reviewed as part of the RCA process

Section 1 - Ward Breakdown Required and Actual Hours based on patient dependency CCDU (Old Ward MH5) to staffing No relation to Staffing issues 2 relating to agency staff not arriving impacted on patient safety No affected staffing levels No have affected staffing levels No patients regarding staffing No Clinical Judgement Vs. Data - the senior nurses felt the ward was safe Recruitment and vacancies. Band 5 x1.7 band 2 x.24 Safety Thermometer results no not report ECIs results do not complete Any serious incidents No

Ward 6 to staffing No relation to Staffing issues No impacted on patient safety No affected staffing levels No have affected staffing levels 2 challenging behaviour patients, awaiting CHC funding. Additional HCA rostered for nights. patients regarding staffing no Clinical Judgement Vs. Data - Ward is under skill mix review which is ongoing. In final stage of pilot. Will be reviewed Feb. Staffing reviewed daily by senior nurses. Recruitment and vacancies. Ongoing recruitment 1 Band 6 not on ward 3.19 WTE Band 5 vacancy plus 1 WTE B5 is counted in establishment but is supernumerary Please note not all staff are on roster due to them being transferred from other departments. Safety Thermometer results - ECIs results green Any serious incidents Yes one flu outbreak.

Ward 12 (Replaces Ward 7) to staffing - No relation to Staffing issues No Not recorded on datix but highlighted to matron and senior management from CTL about the staffing issues on ward 12 due to sickness through the month of January impacted on patient safety - No affected staffing levels Increased from 20 T&O beds to 28 beds as using 8 beds for patients in delay - Due to the staffing issues on ward 12 we have had to monitor the amount of staff on duty in line with potential admissions and acuity on the ward. Fortunately we have had beds in the system but have had to staff some shifts on the ward with off framework to maintain registered nurse numbers. have affected staffing levels RGN 4 HCA 4 Early & Late shift RGN 3 HCA 2 Night shift, Increase in patients from 20 to 28 patients from 18/12/17 patients regarding staffing Staff are aware that there has been a marked increase on the ward in terms of sickness in January which has effected substantive staff. The CTL has written to staff and asked them to be flexible with their off duty so we can try and spread the substantive staff across the week or book our own staff into bank shifts. Matron also working bank shifts on the ward where possible. Clinical Judgement Vs. Data - the senior nurses felt the ward was safe Matron has also moved two staff from the Sheldon unit to the ward for a 4 week period to increase the staffing situation; one HCA and one RN. Recruitment and vacancies. Band 5 x 3WTE Safety Thermometer results 100% ECIs results 97.4% Any serious incidents No

Ward 8 to staffing - No relation to Staffing issues Yes. Two (2) incidents on agency staff who Did Not Arrive. impacted on patient safety - No affected staffing levels Full occupancy rate except: the period the ward was closed for admission during the Flu outbreak. The ward was closed for new admissions for five (5) days Kept some stroke capacity due to NO Pts on the waiting list have affected staffing levels patients regarding staffing No Clinical Judgement Vs. Data - the senior nurses felt the ward was safe recruitment and vacancies. Band 6: 1 Band 6 nurse from the Complex Care unit still on trial. Band 5: x 3 Post to be re-advertised Band 2HCA x 2 Post to be advertised (advert on NHS Jobs) Safety Thermometer results 100% ECIs results 98.5% Any serious incidents No

Ward 5 (replaced Ward 14) to staffing - No Any incidents recorded on Datix- NO impacted on patient safety No affected staffing levels No have affected staffing levels 3 patient requiring 1:1. Extra staff booked to support patients regarding staffing No Staffing is discussed during safety huddle Clinical Judgement Vs. Data - the senior nurses felt the ward was safe The nurse in charge ensured that care was prioritised and maintained safety. 1 RN from complex care not showing on Maps 2 HCA from complex care not showing on Maps 1 new starter HCA not showing on Maps Recruitment and vacancies 3.71 band 5 WTE - on-going recruitment Safety Thermometer results 96.2% ECIs results 97.5% Any serious incidents yes one fall from bed with head injury.

Willow to staffing No relation to Staffing issues No impacted on patient safety No affected staffing levels Respite patient has increased dependency levels. have affected staffing levels Respite patient has increased dependency level plus 2 patients requiring 1:1 care patients regarding staffing No Clinical Judgement Vs. Data - the senior nurses felt the ward was safe Recruitment and vacancies. band 5 2WTE and 2 band 2 Safety Thermometer results 100% ECIs results 89.9% Any serious incidents Yes flu outbreak.

Sheldon to staffing - No relation to Staffing issues No impacted on patient safety No affected staffing levels No have affected staffing levels A DoLs still in place for next six months During start of January patients regarding staffing No Clinical Judgement Vs. Data - the senior nurses felt the ward was safe Recruitment and vacancies. Secondment of B5 from LD now in place. Complex care team member now part of the team Safety Thermometer results 100% ECIs results 95.4 Any serious incidents No

Perry Trees to staffing No relation to Staffing issues No impacted on patient safety - No affected staffing levels There was significant empty capacity at the beginning of the month - Staff were relocated to other areas and some bank and agency were cancelled have affected staffing levels None patients regarding staffing No Clinical Judgement Vs. Data - the senior nurses felt the ward was safe Recruitment and vacancies. Band 5 x 3.42 WTE on going recruitment Safety Thermometer results 100% ECIs results 91.9% - The unit have had many bank and agency staff on shifts due to vacancies. This has affected the standard of documentation. This is being addressed by the CTL. There are new staff starting in the near future and recruitment continues Any serious incidents yes one fall and fracture this is under investigation via the RCA process. Staffing levels did not contribute to

Anne Marie Howes Centre to staffing - No relation to Staffing issues No impacted on patient safety - No affected staffing levels The unit has had empty capacity throughout parts of January. have affected staffing levels Staffing has been increased on the late shifts to manage patients. One to one supervision has also been required through the month, Extra staff have been rostered as the unit has had up to 7 patients that are at high risk of falls due to their cognitive impairment. The extra staff are essential to maintain safety as the unit layout is single room accommodation. patients regarding staffing addressed by above actions Clinical Judgement Vs. Data - the senior nurses felt the ward was safe Recruitment and vacancies. Band 5 x 1.39 WTE and Band 2 x 4.59, on going recruitment Safety Thermometer results 96.4% ECIs results 98.6%

Community Unit Ward 27 to staffing - No Any incidents recorded on Datix- No impacted on patient safety - No affected staffing levels The unit has increased beds by 5 to support Winter pressures, staffing has been increased have affected staffing levels No patients regarding staffing None Clinical Judgement Vs. Data - the senior nurses felt the ward was safe, Recruitment and vacancies. Band 5 x 0.33WTE Safety Thermometer results 95% ECIs results 93% Any serious incidents No

Ward 9 - Rehab to staffing - No relation to Staffing issues Yes. Four (4) incidents on agency staff who Did Not Arrive or other concerns. One (1) incident concerns with tracheostomy care care impacted on patient safety - No affected staffing levels No have affected staffing levels Consistent number of Hyper Complexity (ROC) wit tracheostomies 4 Minimum number of 1:1 = 4 Patients 15 min checks = 3 patients V&A 2 patients, including Substance A grade user 1 patients regarding staffing No Clinical Judgement Vs. Data - the senior nurses felt the ward was safe recruitment and vacancies. Band 5 RGN: 4WTE employed into and awaiting start (2WTE RGN Students + 1WTE employed 03/02/2018 + 1 WTE will commence 20/3/2018) Band 5 RGN vacant:2wte Band 2 HCAs posts on NHS Jobs and interviews to be held week beginning 13/2/2018 Safety Thermometer results 95.7%

Riverside Lodge Short Breaks (previously LD Hobmoor Road) to staffing - no relation to Staffing issues no impacted on patient safety N/A affected staffing levels temporary closure until 22 nd January and staff attended training between 2 nd 22 nd January. Reduced occupancy during remainder of January. Shifts shown during this period are where staff from RSL supported other bedded areas. have affected staffing levels Increased staffing levels requested and agreed at divisional management level and supported by executive leadership level throughout January, to support reopening and continued service improvement. patients regarding staffing no Clinical Judgement Vs. Data i.e. Clinical the senior nurses felt the ward was safe because whilst bank and agency staff have been required, increase staffing level has been in place during January following reopening on 22 nd January. Concerns raised regarding the availability of additional temporary staffing. recruitment and vacancies. 1 x band

LD Kingswood Bungalows to staffing - No relation to Staffing issues no impacted on patient safety N/A affected staffing levels On the 9 th January the unit was temporarily closed due to a broken boiler, affecting the heating and hot water. Reduced occupancy has been noted during periods where the staffing has been highlighted as under agreed level. have affected staffing levels no patients regarding staffing no Clinical Judgement Vs. Data i.e. Clinical the senior nurses felt the unit was safe as no indication of being below staffing levels, unless adjusted due to occupancy. Concerns raised regarding the availability of additional temporary staffing. Recruitment and vacancies. x1 Band 5 appointed to, awaiting start date. X1 Band 5 vacancy.x1 Band 3 vacancy. Safety Thermometer results N/A

LD Elliott Lodge to staffing - No relation to Staffing issues (86426) Qualified bank staff collapsed whilst on duty. Escorted to UBH QE by ambulance. impacted on patient safety N/A affected staffing levels, 08.01.18 14.01.18 Patient from Riverside Lodge Short Breaks unit accommodated at Kingswood Drive 9. 1:1 support provided day and night to patient by HCA supplied through bank/agency or RSL. Three patients admitted to hospital during January. Two patients remain in hospital. Increased staffing to support needs of patients in general hospital, around communication and person centred care. Unit remains under-occupied by 1, other than 8 th - 14 th January have affected staffing levels Due to ill health of patients, two of the three remaining patients require close observation/monitoring including frequent NEWS, observations. One service user on 2:1 specially commissioned package. patients regarding staffing Due to high levels of staff sickness, qualified duties not filled by bank staffing were covered by unit manager, 24th 26th 29th 30th January. Includes 29th January date further to the deterioration of health of the bank staff whilst on duty. Clinical Judgement Vs. Data i.e. Clinical the senior nurses felt that whilst additional staffing from Bank required all shifts covered to agreed staffing levels. Concerns raised regarding the availability of additional temporary staffing. Recruitment and vacancies. 1 xband 6, 1 x band 5

Section 2: Ward Breakdown Required and Actual Hours based on establishment Update on AHPS into Action and AHP safe Staffing Background The Allied Health Professions (AHPs) consist of fourteen professional groups Art Therapists Drama Therapists Music Therapists Podiatrists Dietitians Occupational Therapists Orthopists Prosthetists and Orthotists Paramedics Physiotherapists Diagnostic and Therapeutic Radiographers Speech and Language Therapists BCHC employs around 700 AHPS across all of its Divisions and Services, with Physiotherapy, Occupational Therapy and Speech and Language Therapy forming the 3 largest professional groups. AHPs focus on person-centred, preventative and therapeutic care. They are accredited, highly trained, autonomous professionals performing a crucial function across the health and social care system. AHPs work with their multi-disciplinary colleagues to deliver care and treatment to service users and carers across all clinical settings and age ranges. They are a core part of each clinical service, and as such it is vital that this workforce is utilised to best effect to support the aim of addressing the 3 main challenges facing the system:- Closing the health and wellbeing gap Driving transformation to close the care and quality gap Closing the finance and efficiency gap Structures AHPs are organised in different ways across the Trust, with some uni-professional teams, such as Musculoskeletal Physiotherapy, managed as standalone services, and others such

as AHPs working in specialist Outpatient clinics in the Rehabilitation Division, managed as part of Multidisciplinary business units. AHPs into Action In January 2017 the Chief Allied Health Professions Officer for England launched the National strategy document Allied Health Professions into Action: Using Allied Health Professionals to transform health, care and wellbeing. 2016/17-2020/21. This is the first time that AHPs working across the health, social care and third sector in England have had a national strategy and the intention of it is clear. It sets out how the AHPs can and do work across the sector to contribute to services users health and well-being, whilst improving efficiency within the system. AHPs into Action seeks to define how the NHS in England would be different if AHPs were genuinely used effectively. The Strategy defines how AHPs can support local Sustainability and Transformation Plans (STPs) and implement actions to respond to the three priorities set out in the Five Year Forward View: driving improvements in health and wellbeing; restoring and maintaining financial balance and delivering core quality standards. It sets out the key Impacts, Commitments and Priorities that the AHPs have collectively committed to delivering on. These are: Impact of the effective and efficient use of AHPs for people and populations Impact 1 - AHPs will improve the health and wellbeing of individuals and populations Impact 2 - AHPs will support and provide solutions to general practice and urgent and emergency services to address demand Impact 3 - AHPs will support integration, addressing historical service boundaries to reduce duplication and fragmentation Impact 4 - AHPs will deliver evidence based/informed practice to address unexplained variances in service quality and efficiency Commitments to the way services are delivered. Commitment 1 - Commitment to the individual. Commitment 2- Commitment to keep care close to home Commitment 3- Commitment to the health and well-being of populations Commitment 4 - Commitment to care for those who care. Priorities to meet the challenges of changing care needs. Priority 1 - AHPs can lead change Priority 2 - AHPs skills can be further developed Priority 3 - AHPs evaluate, improve and evidence the impact of their contribution Priority 4 - AHPs can utilise information & technology. Within Birmingham Community Healthcare Health Foundation Trust, the AHPs felt that it was essential to consider AHPS into Action and make use of it as a methodology for developing local strategy and divisional initiatives. AHP teams from each Division have taken part in a series of listening events and workshops where they reviewed the initiatives in AHPs into Action, mapping against their current services and practice as well as identifying opportunities and ideas for working differently in the future. In addition, these events reflected on the current structures and challenges for AHPs in the Trust and considered models for professional engagement in the future. These workshops included AHPs from the TCT organisations.

A further event was held on the 8 th November 2017 to celebrate and showcase the work being undertaken by AHPs. This event was well attended by AHPs and support staff from across all 3 TCT organisations. Challenges and Opportunities A comprehensive list of good practice and development ideas were generated from these workshops and these are being discussed and progressed within Divisions. A number of challenges were identified and discussed:- AHP leadership across the Trust at Divisional level has not been consistent in the past, with some services lacking professional or managerial leadership at AHP level. The creation of new Heads of Therapy roles within Urgent Care and Adult Community Divisions has addressed this challenge within these divisions and these roles have been pivotal in the xxxx Professional Leadership, clinical supervision and support has been identified as a challenge for divisions where only a small number of an AHP profession are employed It was felt that there should be more opportunity for rotational posts across the Trust. Whilst all Divisions identified the advantages of rotational models, services felt limited in creating rotations within AHP teams because of the lack of central co-ordination of rotations, the difficulty in moving budgets from one Division to another and the perceived risk to service delivery of a more temporary deployment model using rotational staff rather than substantive posts Student education placements were identified as requiring greater capacity and new ways of working to deliver an enhanced experience for significantly more students within the Trust. AHP team leads recognised the need for local review of staffing levels, skill mix and team size and shape in order to better deliver the actions identified both in the National Strategy and in their Divisional development plans. It was identified that professional forums and opportunities to share best practice across the Trust was uneven and many AHPS felt that they lacked influence within service developments. Safe Staffing For AHPs To support NHS providers to deliver the right staff and skills, in the right time and place, the National Quality Board (NQB) published an updated safe staffing resource for NHS provider boards to assure the delivery of compassionate, effective, safe, sustainable high quality patient care. To help to achieve the Five Year Forward View s ambitions, the principles contained in this resource apply to the broader multi-professional workforce in a range of care settings, and do so in a way that optimises productivity and efficiency while maintaining the focus on improving quality Although work-streams have been created for AHP safe staffing models in Acute services across the country, the national guidance on AHP safe staffing tools for Community trusts has not been progressed at present. We have therefore developed a small number of models suitable for piloting in our AHP services, using the outputs from National Acute service pilots as a start-point. These acute services models used either a Clinical Formulary approach, similar to that developed for District Nursing in BCHC or a Job Plan, following the model utilised by Medical Staffing.

A small working party considered key national drivers, outputs from acute safe staffing pilots and previous work undertaken within BCHC AHP services, including the pilot study carried out by Children and Families Physiotherapy and SLT services in the past, using the JJ methodology. This methodology aims to show how safe and effective staffing levels can be calculated using the data and information already available in services, based on a demand and capacity tool Models for use in Adult Communities AHP services have been informed by the Care in Focus work using a clinical formulary approach. The Clinical Formulary Model developed as part of the Care in Focus work for Adult Community AHP services has been tested and is now being used in order to inform team shapes and sizes. Some additional information has been identified as needing further work, specifically a formulary for non-clinical interventions (supervision, peer review, guided assessment) Next steps for BCHC The outputs and feedback from the AHP listening events and workshops, and from the conference have led to the development of a draft BCHC AHP strategy. This is currently being populated with best practice examples, including those from the work on AHP safe staffing. It has been created as a joint document with TCT AHP leads and can be organised into separate sections if required. A number of further steps have been identified to address and discuss challenges 1. The implementation of a professional leadership forum model for AHPs including: a. a regular Divisional professional AHP forum for clinical and service leads to i. Focus on service developments and issues ii. Feed into Divisional Boards, governance, commissioner discussions. iii. This could be managed within each division or jointly with divisions which have similar services e.g. Mental Health and Learning Disabilities, either for every meeting or alternate meetings. Under this model, the forum would then feed into a number of Divisional boards b. A 6 monthly Trust wide AHP Forum, open to all AHP staff and assistants. i. This forum would focus on innovation, sharing best practice, clinical excellence presentations, shared issues such as rotations and students ii. To include Executive level representatives DoNT, NED, ADT These forums would provide a vehicle for progressing the following :- 2. Consideration of a cross- Divisional model for Professional Leadership, clinical supervision and support for AHP professional groups to enable robust support to AHPs regardless of the size of their workforce in a specific Division 3. Centralised, Trust wide support for the management of Rotations in order to facilitate the movement of rotational AHP staff between services and Divisions this could take the form of a hosting arrangement led by one Division on behalf of the others. 4. Development of a comprehensive programme of piloting of new ways of working with student placements in order to increase the capacity for AHP students within the Trust. This work can be supported by the Professional Development team 5. Safe Staffing for AHPS to be further progressed and local solutions tested and implemented in the absence of National models.

Conclusion For January 2018, there were a number of issues related to staffing, including increased dependency of patients on wards 8 and 9 There were no red flags reported. There were 5 serious incidents reported Staffing is being discussed as part of the Safety Huddle being piloted on Ward 5. The report includes notes on progress with implementation of the National AHP strategy and on AHP safe staffing. This report has now been created utilising the one-vision system in order to streamline the production of the report and improve data quality. This is now an automated system which will ensure Information is as contemporary as possible. Work is underway to improve capture of all the data required for this report within the timescales. QGRC are asked to note the contents of this report and offer feedback on its format. Detailed reports available within safer Staffing section within the Trust s online reporting portal http://1vision bhamcommunity nhs uk/