Report to: Board of Directors (Public) Paper number: 4.5 Report for: Monitoring / Decision Report type: Operational Performance Date: 20 April 2016 Report author: Caroline Harris-Birtles, Deputy Director of Nursing Report of: Claire Johnson, Director of Nursing and People FoI status: Report can be made public Title: Six Monthly Nursing Establishment Review Executive Summary The Trust has continued to prioritise work on safe staffing and skill mix at St Pancras Hospital and the Highgate Mental Health Centre, this work is co led by the Director of Operations and Deputy Director of Nursing. Both of the Care Quality Commission comprehensive inspections of 2014 and more recently in February of this year have raised concerns about safe staffing on the inpatient wards and the morale of staff. Work on Safe Staffing covers multiple work streams, and this paper focuses broadly on the Keith Hurst Audit work undertaken in late 2015 and early 2016. However, always in mind is that we are working together to achieve assured patient safety and a healthy working environment for our staff, within the restraints of the current financial climate. Work has been undertaken to help the Trust better understand the reasons why nursing staff leave the trust and why they might choose to remain. Currently just over 50 % of nurses band 5 to 7 have been in the trust longer than five years. In December 2015 the workforce stability index for nursing at Camden and Islington Trust was 77%, indicating that the trust is losing too many talented and experienced nurses. With the CQC reporting poor morale in staff on the inpatient units, it is likely that the high stability index in impacting negatively. Whilst the well managed and effective recruitment campaign of 2015 has gone a long way to improve the continuity and quality of staffing in the inpatient wards it is not the whole solution. Further work is required both on establishing a workforce who remain in the Trust s employ beyond the current mean of 2 years as well as understanding safe staffing in context with an evidenced based tool. The evidence base in relation to workforce planning and safe and effective staffing is less well developed in mental health and older peoples residential and rehabilitation services than it is for acute hospital settings. Health Education West Midlands in conjunction with a number of mental health trusts have now piloted and developed an evidence based tool.
1 The Mental Health Staffing Framework specifically rates the acuity and dependency of patients in psychiatric settings, and provides indicators for required staffing and skill mix. The focus on staffing, patient safety and efficiency continues to be a high profile national agenda. 2 Lord Carter of Cole s independent report into Operational Productivity and Performance in English NHS Acute Hospitals: Unwarranted Variations February 2016 recommends that new methodology be introduced to capture a more meaningful measure of nursing and healthcare support worker deployment. The aim is that commencing in April 2016 and by April 2017 acute trusts will use the principal measure Care Hours per Patient Day (CHPPD), which is a measure already used in Western Australia, the USA and New Zealand. In order to establish reliable CHPPD data a reliance on an effective E-rostering system with capability to utilise wider functionality will be necessary. In the Trust we already use Allocate e-rostering, which is capable of calculating the new principal measure. The purpose of this paper is to provide assurance to the board that the work on safe staffing at Camden and Islington Foundation Trust continues, and to update the board on progress over the last six months. This paper focuses in detail on the two Keith Hurst Acuity and Dependency Audits that have been undertaken. Further work is required to understand the Keith Hurst work in context with our local services. The Keith Hurst model provides one measure of safe staffing and continued work on how the MDT contributes on a daily basis to patient safety, as well as waiting for the CQC full inspection report which will make comment on safe staffing, is recommended. A further benchmarking exercise will be undertaken to understand the unit costs per bed in Camden and Islington when compared to other similar NHS mental health trusts. The Keith Hurst Tool Kit findings and SafeCare: The initial Keith Hurst Acuity and Dependency audits have indicated that an investment in staffing to meet the recommendations for safe staffing and skill mix using this tool is recommended. But that the Safer Staffing group in the Trust is not yet in a position to clearly understand the detail the tool is indicating in context with our local services, MDT involvement and our patient population. The report recommends that further work is undertaken with the ward managers in order that the local environmental impacts can be better understood, as well as taking into consideration their valuable professional judgment. Consideration also needs to be given to the impact that working 12 hour shifts may be having on both the quality of care that patients receive and on the staff themselves where fatigue, poor morale and high staff turnover may be indicated as a consequence of this working pattern. SafeCare an Application that forms part of the Allocate E-Roster system is being trialed across a small number of wards in the Trust. This is a real time application and successfully launching this tool will mean that more data is available immediately concerning safe staffing. This information will also assist the Trust in managing its nursing resources as efficiently as possible across the inpatient wards. The application will collate Care Hours per Patient the new measure for safe staffing which the Trust will be required to report on by 2017. 1 The Mental Health Staffing Framework June 2015. https://www.england.nhs.uk 2 Independent Report into Operational Productivity and Performance in English NHS Acute Hospitals Unwarranted variations February 2016. 2
Recommendations to the Board The Board of Directors is requested to: RECEIVE and ACCEPT the progress made on the Safe Staffing agenda in the Trust; and AGREE the further work on safe staffing proposed in the recommendations. Trust Strategic Priorities Supported by this Paper Excellence Continually improve the quality and safety of service delivery, service user experience and improving outcomes. Innovation Delivering the highest level of quality and financial performance. Rapidly adopt best practice and maintain a culture of innovation in service development. Risk Implications Risk of not being able to deliver high quality care to patients if safe staffing levels are not met. Risk of harm to both patients and staff if the wards do not have safe levels of nurses and the correct skill mix. Legal and Compliance Implications There is a risk of non-compliance with CQC Regulation 18, Staffing. Finance Implications There are financial implications to be considered should an increase in staffing on the inpatient wards ultimately be recommended. On-going work is required to fully understand the Keith Hurst data in context with the local environment, MDT involvement and national benchmarking. This will be presented in a further paper to the Trust Board. Single Equalities Impact Assessment N/A Requirement of External Assessor/Regulator The Chief Nursing Officers guidance requires that the inpatient nurse staffing establishment is discussed every six months. Monitor and the CQC require the Trust to follow this guidance. Consultation Safe Staffing Committee. 3
Six Monthly Establishment Review 1. Introduction 1.1 The Trust has continued to priorities work on safe staffing and skill mix at St Pancras Hospital and Highgate Mental Health Centre, this work is co led by the Director of Operations and Deputy Director of Nursing. Both of the Care Quality Commission comprehensive inspections of 2014 and more recently in February of this year have raised concerns about safe staffing on the inpatient wards and the morale of staff. 1.2 Work has been undertaken to help the Trust better understand the reasons why nursing staff leave the trust and why they might choose to remain. Currently just over 50 % of nurses band 5 to 7 have been in the trust longer than five years. In December 2015 the workforce stability index for nursing at Camden and Islington Trust was 77%, indicating that the trust is losing too many talented and experienced nurses. With the CQC reporting poor morale in staff on the inpatient units, it is likely that the high stability index in impacting negatively. Whilst the well managed and effective recruitment campaign of 2015 has gone a long way to improve the continuity and quality of staffing in the inpatient wards it is not the whole solution. Further work is required both on establishing a workforce who remain in the Trust s employ beyond the current mean of 2 years as well as understanding safe staffing in context with an evidenced based tool. 1.3 In July 2014 Nice published Guidelines for Safe Staffing for Nursing in Adult Inpatient Wards in Acute Hospitals. The recommendations however, are relevant to Mental Health inpatient settings and have been incorporated into the NHS England programme of work on safe staffing in the Mental Health setting. There is no single nursing staff-to-patient ratio that can be applied across the whole range of wards to safely meet patients' nursing needs. Each ward has to determine its nursing staff requirements to ensure safe patient care. The guideline makes recommendations about the factors that should be systematically assessed at ward level to determine the nursing staff establishment and recommends on-the-day assessments of nursing staff requirements to ensure that the nursing needs of individual patients are met throughout a 24-hour period. 1.4 The guideline also makes recommendations for monitoring and taking action according to whether nursing staff requirements are being met and, most importantly, to ensure patients are receiving the nursing care and contact time they need on the day. The emphasis should be on safe patient care not the number of available staff. 1.5 NHS England have supported a programme of work led by Health Education West Midlands to provide tools that help Mental Health and Learning Disability Services consider their staffing numbers, skill mix and contact time. The evidence base in relation to workforce planning and safe and effective staffing is less well developed in Mental Health and older peoples residential and rehabilitation services than it is for acute hospital settings. Health Education West Midlands in conjunction with a number of Mental Health Trusts have now piloted and developed evidence based tool kit. The Mental Health Staffing Framework specifically rates the acuity and dependency of patients in psychiatric settings, provides indicators for required staffing and skill mix, and provides a broad framework for reporting to the Trust Board 1.6 3The Mid Staffordshire NHS Foundation Trust Public Inquiry chaired by Sir Robert Francis QC called for greater openness and transparency in the NHS together with the need to ensure nursing staffing levels were set and reviewed regularly. From June 2014 there has been a national requirement for all hospitals to publish information twice a year to 3 Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry.01/ 2013
demonstrate that the nursing establishment has been reviewed on each ward and approved by the Board of Directors; and in a move towards further assuring public confidence staffing levels are also reported locally every day for each ward, to demonstrate safe staffing and skill mix. The daily staffing must also be published on the Trust website. 1.7 The focus on staffing, patient safety and efficiency continues to be a high profile national agenda. 4Lord Carter of Cole s independent report into Operational Productivity and Performance in English NHS Acute Hospitals: Unwarranted Variations February 2016 recommends that new methodology be introduced to capture a more meaningful measure of nursing and healthcare support worker deployment. The aim is that commencing in April 2016 and by April 2017 acute trusts will use the principal measure Care Hours per Patient Day (CHPPD), which is a measure already used in Western Australia, the USA and New Zealand where a better grip on efficiency and assurance is evident. In order to establish reliable CHPPD data a reliance on an effective E-rostering system with capability to utilise wider functionality will be necessary. In the Trust we already use Allocate e-rostering, which is capable of calculating the new principal measure. 1.8 The purpose of this paper is to provide assurance to the board that the work on safe staffing at Camden and Islington Foundation Trust continues, and to update the board on progress over the last six months. The paper focuses in detail on the two Keith Hurst Acuity and Dependency Audits that have been undertaken. 1.9 Work on Safe Staffing covers multiple work streams, and this paper focuses broadly on the Keith Hurst Audit work undertaken in late 2015 and early 2016.However, always in mind is that we are working together to achieve assured patient safety and a healthy working environment for our staff, within the restraints of the current financial climate. 2. The National Picture 2.1 Lord Carter of Coles report reveals that the increased demand for nurses post Francis has been significant, and the 5Royal College of Nursing s London Safe Staffing Report 2015, in its annual assessment, revealed that there are 10,000 nursing vacancies in the capital, a vacancy rate of around 17%, with Mental Health nurses proving to be in particularly short supply. The current picture at Camden and Islington is fortunately not this bleak and the vacancy rate for Registered Nurses was reported as 3.3% at the end of January. This is mainly due to the successful recruitment campaign undertaken in 2015 which focused on the newly qualified nurses from Middlesex University, and the investment in continuing support for these nurses. 2.2 Simon Stevens, Chief Executive NHS England requested that Jane Cummings, Chief Nurse NHS England, incorporated nurse workforce planning into the five year forward plan initiatives. 6The Five Year Forward View (October 2014) states that in order to succeed the NHS, will be required to support its workforce. The sustainable transformation plan (STP) cannot become a reality unless there is a committed workforce with the right numbers, skills, values and behaviours. NHS Education will work with employers to identify education and training requirements, and develop new health care roles to meet new patient needs, so increasing the flexibility of the workforce. 2.3 7The Shape of Caring Review, (Raising the Bar) published in March 2015; aims to ensure that throughout their careers nurses and care assistants receive consistent high quality education and training which supports high quality care over the next 15 years. 5 Royal College of Nursing Safe Staffing Report 2015. An annual review of safe staffing in the Region. 6 The Five Year Forward View DOH 2014 7 Raising the Bar; Shape of Caring. A review into the future education and training of Registered Nurses and Care Assistants. Lord Willis Health Education England 2015 5
2.4 In February 2016 Camden and Islington Nursing Executive responded to the Health Education England national consultation on the new proposed support Nurse role yet to be named, and we support this proposal. We are also engaged in the Capital Nurse programme which is a programme that is aligned to the London Workforce Strategic Framework and focuses on four work streams, Developing Career Pathways, Employability of student nurses, use of agency staff and Transition to the new funding arrangements for pre-registration nurses. The Trust is continuing to fully support the Trainee Mental Health Worker training programme along with Practice Placements for prospective nursing students. The objective is that we are fully involved in creating a work force fit for the future, and one that will help us to address safe staffing over the years to come. We intend to review the career pathways of our bands two to four who provide significant care and treatment and who we are very reliant on as part of our new care pathways. 2.5 The national focus on driving down expenditure on agency staffing whilst not impacting adversely on patient care continues. In a letter to the Chief Executive dated 17 March 2016 from NHS Improvement, a financial ceiling for the Trust has been set. To achieve this ceiling or beneath, it will be important to set the inpatient staffing at the right level for patient safety. Currently temporary staffing for nursing is supplied though NHSP and is not included in the agency cap. 3. Camden and Islington Context to date 3.1. Health Roster SafeCare Update 3.2. Following the successful implementation of an NHSP Interface with HealthRoster across all inpatient wards, close to 100% of all NHSP requests are now being made via HealthRoster. For the first time the Trust now has visibility of both substantive and temporary staffing information within a single system which has greatly enhanced our workforce reporting capabilities in relation to safer staffing. 3.3. In November 2015, the Nursing Directorate, working with IT, successfully bid for funding via the Nursing Technology Fund and part of this fund has been used to purchase the HealthRoster SafeCare Tool. SafeCare is a web application optimised for tablet devices, which puts live staffing data in the hands of ward/unit managers, matrons, senior nurses and operational departments. It has been specifically designed to enable daily reviews of the shift-by-shift staffing issues across units and sites, Trust/organisation-wide. 3.4. The implementation of SafeCare is scheduled to start on March 10 th 2016. It will be initially piloted on the following wards: Sapphire Ward; Garnet Ward; and Montague Ward. Once live, SafeCare will clearly show how safe each ward/unit is, shift-by-shift, utilising information contained in HealthRoster and NHSP as well as patient acuity and dependency information captured during the daily census. The census is completed three times a day and is based on the Keith Hurst Multiplier tool kit, this is fortuitous as this approach to capturing patient acuity and dependency has already been undertaken on the wards in November/ December 2015 and January/February 2016, thus meaning that staff will already be familiar with the approach. 3.5. SafeCare also allows changes to be made to the planned roster on the go which will mean data will be more accurate and real time, facilitating better deployment of staff on a shift by shift basis and supporting the operation of the virtual team. 6
3.6. The pilot is expected to take two months, following which SafeCare will then be deployed across the remaining wards by June 2016. 4 The Mental Health Staffing Framework 4.1 In 2012 NHS England launched the 8Compassion in Practice Programme. Action Area 5 is focused on safe staffing and with Ensuring we have the right staff, with the right skills, in the right place. This action area is concerned with the local determination of a suitable staff mix of competency, experience and education in order to best improve the experiences of service users and staff. The aim of this action area was to use evidence, both national and international, to provide a series of tools to determine, locally, the most appropriate staffing levels for a particular health and social care setting that reflects and delivers quality of care, productivity and a good patient or user experience. 4.2 Among a range of recommendations this action area recommends that Directors of Nursing in trusts should agree staffing levels through the application of evidence based tools. At the time the document was published there were no reliable tools for use in Mental Health services, and Health Education West Midlands in partnership with NHS England worked to developed a new framework for senior mental health professionals to ensure the a wellresearched validated tool was available. The Mental Health Staffing Framework was launched in June 2015. Camden and Islington Foundation Trust have already utilised the essence of the framework in its reporting on staffing to Board. This paper reports on the Keith Hurst Multiplier tool for assessing the acuity and dependency of patients in our inpatient settings. 4.3 The Keith Hurst Tool for Assessing Acuity and Dependency in Mental Health settings is not dissimilar in its application and design to the Shelford Group Safer Nursing Care tool used in 2014 at Camden and Islington. (Shelford is an elite group of acute trusts). It involves ward staff conducting an audit of the patient s acuity and dependency whilst on the ward, this is done for 28 consecutive days, and this is followed by a further repeat audit within two months. 4.4 Two audits have been conducted for the Highgate Mental Health Centre and St Pancras Hospital inpatient wards. The first audit was carried out in November / December 2015 and the second in January 2016. Learning from the first audit by ward managers led to more consistent results in the second audit. The Meridian online system was used for collecting the data. 5. Data Quality: 5.1 The overall response rates were 80% for the 2015 audit and 71% for the 2016 audit, which demonstrated a marked improvement on the Shelford Group census data previously undertaken at Camden and Islington Trust 6. Tool Dependency Levels: 6.1 Patient acuity and dependency is ranked across five levels: 1. Dependency level 1: General observations, self-caring service users who are able to do most daily living activities. Core therapeutic interventions are provided. 2. Dependency level 2: General observations. More dependent on the ward staff for personal care needs, requires more than base- level core interventions. 3. Dependency level 3: may be on intermittent observations. Heavily reliant on the ward team for his / her safety and care. 7
4. Dependency level 4: May be on intermittent observations or 1:1 Observations for part of the day. Dependent on ward team for safety needs. Requires high engagement and intervention. 5. Dependency level 5: Enhanced observations. Requires high engagement and observations 24 hours a day. 6.2 The data is entered into the Hurst algorithm, which produces data on: dependency levels of patients, establishment requirement and number of qualified and unqualified staff needed per shift. 6.3 Since the two audits were conducted the author Keith Hurst has undertaken a further review of the tool, and two further dependency levels have been added for patients who are on 2:1 observations or higher, and have greater levels of need that the original five levels were able to assess. 7. Audit Moderation: 7.1 During the second audit a moderating exercise was conducted. (See Appendix 1) This exercise was an adapted level 2 Benchmarking from the Mental Health Staffing Framework. This exercise involved a number of semi structured interviews being conducted with the ward managers. Key findings were positive and staff appreciated and understood the work the Trust was undertaking on determining safe staffing levels. Overall engagement with the audit was good and where gaps had occurred ward managers were encouraged to enter data retrospectively. The main area of ambiguity was around escorting patients and facilitating discharge, which did not seem to reflect adequately in the dependency scores. There was a default trend to rate patients based on their risk profile and not fully appreciate the dependency component, which may not be associated with patient risk. From the audit is was also apparent that informal patients who smoke or required frequent movement in and out of the ward, caused time demands on staff that are not necessarily captured in their dependency level. However, this is new tool and feedback to the author will be undertaken in order to inform further development. 8. Audit Findings: 8.1 Dependency levels: Table 1: Mean number of patients at each dependency level, across division / ward type November 2015 audit. 8
Table 2: Mean number of patients at each dependency level, across division / ward type February 2016 audit. 8.2 The above tables provide the average scores accumulated during the monthly Keith Hurst audit of acuity and dependency. 8.3 Table 2 details the second audit and the data is as broadly as expected and is slightly more consistent than in table 1. The acute treatment wards have higher scores in Departments 3, 4 and 5 so reflecting a higher level of dependency and acuity when compared to the three Recovery and Rehabilitation wards where there are more patients in the lower departments. The Sapphire assessment ward and Coral PICU also score more frequently in the high dependency department and have a low average number of patients with low levels of need. 8.4 The SAMH wards showed an interesting picture across all 5 departments. This likely reflects the high level of need for patients who are suffering from an organic diagnosis, as well as those patients who are more independent and waiting to move from the ward. 8.5 The Keith Hurst tool has not been widely used. It is however the first reliable Mental Health specific tool for measuring patient acuity and dependency and the acute general equivalent has been widely adopted. The audit results appear to be an accurate representation of patient acuity and dependency on the wards at St Pancras Hospital and Highgate Mental Health Centre. 9. Projected Staffing based on audit results. 9.1 The Keith Hurst audit tool projects staffing requirements based on selected predetermined and Trust specific criteria for staff to patient ratio and headroom. Headroom is lost time, and includes, annual leave, sickness, training, and other leave as applied for each member of staff. 9.2 The National Safer Staffing Alliance have used available evidence to demonstrate that less than 1 registered nurse to 7 patients is considered unsafe and would not be a satisfactory minimum staffing level. Adverse patient outcomes are associated with poor Registered Nurse ratios such as failure to rescue and increased mortality rates. 9.3 Although we are not yet in a position to report in detail on the projected staffing as indicated by the Keith Hurst tool, the picture emerging for night duty indicated low levels of staffing were required throughout the night, and upward adjustments to the projected staffing numbers will need to be made to ensure that basic health and safety requirements are met. Whereas, for day shifts where the dependency of the patients is greater, an increase in staffing would be recommended. 9.4 In June 2015 the National Nursing Research Unit published '12 Hour Shifts: Prevalence, Views, Impact'. This work forms part of the national Compassion in Practice Action Area 5 following the Francis review. It states that the provision of 24-hour nursing care inevitably involves shift work and flexible working, including long days. However, these shift patterns have become increasingly controversial, with concerns raised over performance, fatigue, stress and patient safety. 9
9.5 The report captures and reviews a very wide range of literature and in partial conclusion states that On balance, the majority of the studies reviewed showed some degree of negativity, either for nurses, patients, or both, towards 12-hour shifts. Many of the adverse outcomes are fatigue related. 9.6 The controversial nature of working twelve hour shifts requires onward monitoring and further discussion within the Trust as to the impact this pattern of working may be having on patient outcomes, staff wellbeing, morale and turnover. Currently the wards are staffed using a mixture of shifts patterns which include, 12 hour shifts, a 3 shift pattern and a combination of both across a four week roster. Staff are varied in their opinions as to which pattern suits best, and often views are subjective and impacted by family and personal circumstances rather than outcome for the patient. 10. Discussion 10.1 The Keith Hurst tool kit was developed though robust methodology, which included identifying and observing many thousands of nursing interventions, time and motion analysis and also took into consideration environmental factors and professional judgment. The tool was trialled across 6 trusts for four weeks prior to being launched for national use in July 2015. 10.2 The tool kit, which has set background multipliers for staffing and skill mix against reported patient acuity and dependency has so far not been assessed or reported on in the national context. However, the principals that mirror those of the Shelford Group Census tool are endorsed by Nice. 10.3 The audit results for patient acuity and dependence do appear to be correct for the range of inpatient wards at St Pancras Hospital and Highgate Mental Health Centre, and the projected staffing requirement for the wards takes into consideration increased need in the daytime and decreased dependency at night. We are not yet in a position to confirm the staffing requirements as further work is required. 10.4 This Safer Staffing Alliance manifesto is helpful in determining the registered nurse to patient ratio which should not be less that 1 nurse to 7 patients; however, controversy regarding a 12 hours two-shift pattern continues to be a national agenda, which cannot be ignored by the Trust. Nursing and care staff reported low morale to both CQC comprehensive inspections and the commission considered this in its domain results. The last three years of the national Staff Survey have found the trust as the worst performer in London, whether a 12 hours shift pattern is impacting on these results deserves to be better understood. 10.5 The staffing and skill mix applied in the Keith Hurst tool is based on nursing compliment only and does not take into account other staff such as psychologies, occupational therapists or doctors who also support patients. Neither are the local environmental aspects considered in the Staffing multipliers and these may have an impact. There is a 9% ready for action uplift applied, which could be considered too high as at Camden and Islington the Ward Managers are supernumerary to the clinical shift workers. 10.6 Other measures should also be considered in conjunction with the Keith Hurst tool and Benchmarking against National NHS data for similar Mental Health trusts would be helpful in understanding the local position. Unit cost per bed and staff per patient measures would be beneficial. 10
11. Recommendations 11.1 The following recommendations are proposed as a result of the work by the Safer Staffing group: 1. The professional judgment of the Trust ward managers should also be taken into account, alongside the audit findings. This would allow for adjustment of staffing and skill mix in context with the local ward environment and patient population. We propose a set of individual interviews with the ward managers and matrons to achieve this. 2. The Keith Hurst tool kit should be repeated at six monthly intervals, although with the introduction of SafeCare across the wards, it should be possible to gather the audit data from this source which will be far more reliable as data is captured three times a day regarding the acuity and dependency of the patients. 3. A benchmarking exercise against other Mental Health trusts regarding the two shift verses three shift pattern. Further work in the trust to understand how the 12 hours shift pattern may be impacting on the workforce morale, retention of staff and patient safety and outcomes is required. 4. Set up a group to include Human Resource, Finance and Nursing to understand the financial assumptions that the tool applies. 5. To understand the current overspend on NHSP and Agency staff, which can be described as assigned hours, in terms of the reasons for booking extra staff. 6. The Keith Hurst Tool does not include other Allied Health Professionals (AHP s) such as Occupational Therapists, Psychologist or Psychiatrists in its calculation of safe staffing levels. Review work at ward level to understand the contribution of AHPs in the Trust to safe staffing is indicated. 7. National Benchmarking against other NHS Mental Health trusts for Unit Cost per bed, and nursing staff per patient. 8. Ensure that any recommendations of the final CQC report that concern safe staffing are included in the Safe Staffing work. 11
Appendix 1
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