Meeting of the Board of Directors public session Safer Staffing Planned and actual staffing levels Wednesday 29 th April 2015 Agenda item 12 Reason for item: This is a standard monthly report on the planned and actual nursing staffing levels. It includes the data that is submitted nationally to NHS England. Summary: The report presents the planned and actual staffing levels for March on all inpatient wards. The average fill rate for each ward together with Nurse Sensitive Outcome Indicators is provided in Appendix 1. This enables the Board to triangulate staffing levels with quality indicators. The Board should note that: Achieving high fill rates for night shifts continues to be prioritised Vacancy levels and the additional beds opened in 2014/15 continue to be the biggest challenge. During March a day care facility was also utilised providing 76 occupied bed days, substantive staff supported the ward to ensure that care remained safe. Divisional Senior Nurses review staffing levels on each shift and take action to ensure that patient care remains safe and effective. Board Action required: The Board is asked to: 1. Review the information provided and the actions in place to achieve and maintain staffing levels that will enable safe and compassionate care to be delivered to our patients. 2. Agree any further actions that are required. Report from: Bev Hall, Deputy Director of Nursing Report sponsor: Theresa Murphy, Director of the Patient Experience & Nursing Links to Trust strategic priorities: To create a patient centred organisation to deliver improvements in patient experience and the quality of care we provide. Previous consideration at Board or Committees: this is a standard monthly report. Equality and diversity considerations: none. Financial implications: There are no direct financial implications arising from this monitoring report; however the ongoing drive to recruit substantive staff outlined in the report will have a positive financial impact by reducing reliance on agency staff. 1
1. Introduction Planned and Actual staffing levels This report provides the Trust Board with an overview of registered nursing, midwifery and care staff levels across day and night shifts in inpatient areas. A table (Appendix 1) sets out the planned and actual nursing fill rates by ward, providing an at a glance overview, it also includes a range of Nurse Sensitive Outcome Indicators (NSOI) that may be associated with the impact of gaps in staffing levels. 2. Key Points This report has used information generated by the e-rostering system; the reported fill-rate is based on the number of nursing hours deployed as a percentage of number of nursing hours planned in the rota. The table below shows the average fill rates for March across both sites Site Day Night Average fill rate RN/RM % Average fill rate Care staff % Average fill rate RN/RM % Average fill rate Care Staff % Hillingdon 87.6%. 90.5% 103.9% 112.4% Mount Vernon 90.3% 92% 102% 148.7% The average fill rate of RN and care staff during the day at the Hillingdon site was higher this month than in February, with the highest rate for RN in 2014/15. Mount Vernon fill rates for days and night for RN and HCA have also increased. The trend for better fill rates at night across both sites continued. 2
Staffing during March remained challenging, contributory factors remain unchanged and include: The impact of AMU opening in place of EAU, with an additional 16 beds The impact of Marina moving to Fleming, with a net gain of 15 beds The continuing volume of three extra capacity wards open A day care facility had 76 occupied bed days recorded during March Vacancy levels above planned Acuity and Dependency of patients, resulting in the need to increase staff above the planned levels on some shifts to provide the care or additional supervision required. 3. Actions to address gaps Planned and actual staffing levels are reviewed on a shift by shift basis by the ward sister and matron and discussed at the daily capacity meetings. Plans to ensure safe staffing are formulated and agreed at the daily capacity meetings in conjunction with the Director of Patient Experience & Nursing. Where a shift is running below the planned level of staffing other elements will be reviewed, such as the activity on the ward, the acuity and dependency of the patients and the experience and skills of the actual staff on duty. In some circumstances it may be safe and appropriate to provide care with the actual staff on duty. In this situation staff will be especially vigilant to any aspects of care that is at risk of being missed and escalate their concerns to Senior Nurses for further action. If the actual level or experience and skills of staff is assessed as insufficient for the needs of the patients further action will be taken with the aim of maintaining safe and effective nursing care for our patients. Examples of actions taken to address any gaps in planned staffing levels include: Reallocation of staff from within the division or other divisions in the Trust Support from non-ward based nursing/midwifery or care staff Matron working clinically providing hands on care Requests for bank or agency staff. 3
3.1 Recruitment Update Detailed information about actions planned or underway to support recruitment and retention can be found in the Recruitment and Retention section of the quality and performance report. 4. Divisional Overview and Assurance 4.1 Medical Division Russell Wernham and Helen Hardy, Assistant Director of Nursing Alderbourne Patients requiring tracheostomy care are being nursed on the ward. Additional registered nurses are required each shift which accounts for the high fill rates. Sub optimal staffing incident reports have been completed to show the areas of shortfall despite agency requests. The ward s own trained staff are undertaking additional bank work to address the skill mix. In addition a 1 WTE band 6 Junior Sister has been filled and recruitment to band 5 posts is ongoing. The ward is currently scoring 100% of patients being extremely likely or likely to recommend the ward. Beaconsfield East (B East) Beaconsfield East staffing has remained consistent to previous months. Medication errors are being managed with support from the matron. The ward FFT is currently scoring at 92% of patients being extremely likely or likely to recommend the ward. Bevan Bevan has recruited to nearly all of the vacant posts. The ward continues to support the extra capacity ward by providing Band 6 level junior sisters. Bank usage is high to support the use of specials for falls in patients mainly with detox related confusion and instability. This is also reflected in the three falls, including one with harm. There has also been a pressure ulcer this month and the ward are being supported by the tissue viability nurse. The ward is currently scoring 100% for the FFT which reflects the care and compassion provided by staff on the ward. The recent patient story at Board was from Bevan Ward. CCU CCU has had several staff members leave over the last month and as such has had an increase in bank and agency use. The HCA hours are on the roster but only used to support during periods of increased acuity. The unit have had one pressure sore this month and have been supported by the Tissue Viability nurse. The Unit has scored 100% this month with patients recommending the Unit. Daniels Daniels has 14 beds open with a plan to increase to 16 in May as bathroom facilities are completed. The low fill rate for days can be accounted for the Ward Sister using 4
her professional judgement to reduce the RN on a late shift until the ward is fully open to 16 beds. On nights the fill rate for care workers is high, 183% this is due to additional staff booked to special at risk of falling. Given the current bed occupancy there is a minimum of one registered nurse to seven patients. It is worth noting that night shifts are easier to fill than the day. The low FFT score 67% is usual and the narrative will be analysed to better understand this dip in performance. Drayton The patient demographic on Drayton remains very challenging with some extremely confused and wandering patients. This poses problems as the ward does not have a lockable door. Specials have been requested to support these patients. The ward still has multiple staff on maternity leave. The falls on Drayton reflect the high dependency of the patients. The friends and family test has dropped this month to 89% and staff are working hard to improve this score. AMU The Unit remains challenged with staffing. There is high agency use as the ward continues to increase its establishment to reflect the 46 beds. The increased agency use will begin to reduce as we have now recruited to eight of the ten band 6 posts on the ward. The ambulatory care service is now fully recruited to. Falls on the ward have been high this month and root cause analyses (RCAs) have been completed for those with harm. Grange Grange ward has nearly filled all the vacancies at Band 5 and 6. We are working with Learning & Development to increase the skill set of these new staff. We have used multiple agency this month to cover the high acuity patients on Non Invasive Ventilation. These have increased to eight patients at its peak. Sub-optimal staffing has been addressed with dynamic risk assessment on a daily basis. The ward has had several pressure ulcers and the Tissue Viability nurse is supporting the staff and patients. Hayes Hayes ward has remained very busy with multiple confused patients. The staff have been over established to meet the needs of the patients on the ward. Pressure ulcers remain a problem and the senior staff on the ward are working to increase the awareness of these. The reporting of pressure ulcers has improved. Falls are well reported and all with harm have had a Root Cause Analysis commenced. Stroke The ward bed capacity continues to fluctuate between 20 26 with additional bank/agency being used as necessary. Recruitment to a band 6 vacancy is ongoing with interviews scheduled for end of April. 5
Edmunds Staffing on Edmunds is much improved with a significant reduction in the amount of bank and agency being used. The FFT is much improved in month with 100% of friends and family extremely likely or likely to recommend Edmunds ward. Pinewood Pinewood continues to have high care staff fill rate overnight due to the need for 1:1 specials for confused elderly patients at risk of falling. The one episode of suboptimal staffing was where additional staff could not be resourced despite agency request. The ward has had six falls in month, none resulting in harm. Safety awareness is being discussed at ward meetings. The FFT this month is significantly improved at 100% overall satisfaction. Churchill Churchill continues to see a high level of bank and agency use. Actions to strengthen the stability of the workforce on Churchill are in place with substantive staff from other well established ward areas being redeployed on a three month basis. This will ensure better continuity of care and a safer roster. Staff sickness is also higher than average on this ward which is being managed in conjunction with HR and the Matron. The number of falls on the ward remains high and specials are being booked to mitigate the risk of recurrent incidents. Medication errors have been reviewed and staff involved have reflected on the errors and actions and learning agreed. Lister The ward leadership team is now fully recruited with ongoing work to fill vacancies at band 5. This is ensuring a better level of continuity in the care. The high staff fill rate at night is due to the need for specials in terms of a confused patient. The current percentage of friends and family extremely likely or likely to recommend Lister ward stands at 100%. General Overview The Division has been working hard to increase the levels of ward staff completing STaM and also MCA/DoLs training. This has seen our figures rise from 30% to over 80% in key training such as Infection Prevention and Control and Safeguarding. 4.2 Surgical Division Sinead Fagan, Assistant Director of Nursing The safety of all the surgical wards continue to be assessed on a daily basis by the matron and Assistant Director of Nursing for Surgery. Agency staff members who have been working regularly have been given permanent shift lines to support greater consistency in the workforce and care delivery. 6
Jersey Staffing fill rates on the ward continue to increase month on month; it is now currently at 86 % for March (due to vacant posts) and 110 % at night. We have always strived to maintain one of our substantive members of staff on the ward to cover night shifts. The increase at night time is due to patients requiring 1:1 nursing care. These vacant day shifts were filled with bank and agency RGNs where possible. Health care assistant shifts were filled to 79% seeing a slight drop also. Recruitment of a Band 6 nurse has taken place to ensure safer staffing and leadership within the ward. Recruitment has been ongoing on a monthly basis; however temporary staffing solutions are still required to cover vacant shifts. 1.7 -staff nurse vacancies - Band 5. 3 HCA vacancies (actively been recruited into) The ward has had an increase in the number of higher acuity patients, mostly step down from ITU/HDU. The ward has also had patients who require 1:1 nursing care due to the risk they posed to themselves. 95% of responses from friends and family test stated they would be likely or extremely likely to recommend the ward. Two patients responded with an extremely unlikely comment. This was due to staff attitude with the staff members named. The ward manager and matron are addressing this directly with the staff concerned. We have seen an improvement this month in our nurse sensitive indicators. Our nurse sensitive indicators show zero hospital acquired pressure ulcers and one fall resulting in no harm. Matron and sister continue to drive the assessment; documentation and ensuring the patients remain safe whilst in the care of the Trust. Two medication errors have occurred on the ward. Safety and assessments of patients is paramount through the ward; the ward sister and the nursing team continue to ensure that this is maintained. Kennedy Staffing fill rates are 88%. This is a significant improvement on the last couple of months with recruitment that has taken place and the new staff in position. The opening of Fleming ward has also had an impact on the safe staffing of Kennedy ward due to a sister temporarily redeployed to work on Fleming. This staff member has now returned to Kennedy Ward. Positions have been filled by bank and agency members of staff where possible. The clinical need of the patients and staffing levels are continually being reviewed by the Sister and Matron with provisions made to cover where possible by reallocating staff from other surgical areas or Matron assisting in clinical practice. We had one datix incident stating that the ward was understaffed. Substantive registered Nurse fill rates at night were prioritised to ensure safe care, with additional one to one specials in place when required for specific patient conditions. The fill rate for March on Kennedy Ward was 111% at night shift due to a requirement for 1:1 nurse to patient ratio for some patients for some nights. 7
Substantive nursing positions continue to be recruited to and sickness management has been undertaken for those staff requiring it. 1.78 staff nurse vacancies. 3 HCA vacancies ( 2 of these staff new members starting in May) 100% of received FFT responses stated they would likely or extremely likely recommend the area. Most of the commentary was very positive with compliments for the nursing staff and care delivery. We continue to strive in getting more feedback from the Friends & Family Test. There was one fall with harm recorded and three hospital acquired pressure ulcers. We now have an agreement to keep three pressure relieving mattresses on the ward for all patients requiring one on admission. The dependency on the ward has been extremely high over the last two months. We have many patients who are bed bound and require one to one nursing care both at night and day time. This has been provided where possible by increasing the nursing establishment during the day and night time. Trinity Ward In January Trinity has a fill rate of 97%, this is an increase from last month. All night shifts were covered appropriately. The vacancy rate on Trinity has been reduced after successful recruitment to meet the funded establishment. The ward has one RN currently off on long term sickness. Temporary staffing has been used for backfill. Trinity Ward staffing fill rate reflects the activity associated with the ward. Staffing levels were increased in line with the number of patients on the ward as activity fluctuates but the planned numbers are based on an assumption of full occupancy. There was one fall, one pressure ulcers and one medication error. These incidents have been investigated by the ward sister and matron. ITU Staffing in ITU fluctuates depending on the patient acuity. ITU patients require a ratio of 1:1 (RN:Patient) whereas some HDU patients can be nursed on a ratio of 1:2 (RN:Patients).This is monitored on a daily basis by the ITU senior nurse manager, with staffing levels adjusted accordingly in line with acuity and actual patient present on the unit during the month. For March 72%% of shifts were filled in line with patient activity. Bank and agency staff were utilised as required, however the unit was able to redploy their staff elsewhere in the Trust when the unit had fewer or lower acuity patients. There were no required shifts that were unfilled meaning that the staffing hours met the needs of the patients on ITU/HDU during March. ITU has had one medication incident reported. The unit also reported zero hospital acquired pressure ulcers. One fall was reported also during safety thermometer check. ITU has now a Band 7 position vacant due to internal promotion as Unit Manager. 8
Fleming Ward Fleming Ward opened as a ward in the surgical directorate in January 2015. The ward has 15 beds that are utilised for gynaecological inpatients and there are 14 beds on the surgical assessment unit. 83% of day shifts were filled throughout the month and nearly all night shifts. During March a number of patients required additional night time supervision due to confusion, this 1:1 care and supervision was provided by additional care assistants. There is a substantive and experienced band 7 senior sister and there will be three band six junior sisters in post by the end of April, this will provide strong leadership for the ward. There is an active recruitment for the ward but in the interim suitable bank and agency staff are being given permanent lines of off duty to maintain greater continuity for the patients and the substantive ward team. We are working with recruitment to ensure that we can have a substantive team going forward. There are currently: 7 Band 5 vacancies (2 currently on induction and 5 out to advert) 2 Band 6 vacancies out to advert. Fleming Ward scored 96% in FFT in March, some patients commented on the lack of TV and Wifi on the ward but mostly patients were very pleased with the care been delivered on the ward. No harms have been reported through the Safety Thermometer. However there were two medication errors; these have been addressed with ward staff involved. Matron spends a high proportion of her time on this ward to provide greater vigilance and scrutiny and support the team through the transition and implementation of new pathways and team working. 4.3 Women and Children s Division- Anita Hutchins, Head of Midwifery We have met with e-rostering to see if the issue of the hours discrepancy (3 hours per long day worked) can be resolved as it continues to give an inaccurate reflection of staff cover for shifts. Unfortunately there does not seem to be the capacity to allow flexibility in the system to reflect the correct picture. We are currently over recruited on our budgeted establishment. Outlined below is the management where staff shortfalls have occurred. Labour Ward Currently Labour Ward has a number of staff on long term sickness. All vacant shifts are reviewed and if possible, to allow minimum impact in skill mix, staff are asked to swap shifts if they are able. All vacant shifts are put out to bank and if not filled then agency considered if the activity/acuity levels warrant this. However we have had problems with agency staff not turning up for booked shifts. These do get reported back. 9
When activity levels are above expected levels, then it is necessary at times to relocate staff from other clinical settings following the Maternity escalation and divert policy risk assessment process in conjunction with the maternity bleepholder. Katherine Ward All vacant shifts are put out to bank and agency where shortfalls are identified. However it is not always possible to fill shifts if there is a sudden vacancy e.g. sickness. There were 70.5 hours of unfilled shifts that we were unable to fill with bank and agency and although not ideal were managed through the maternity escalation and divert policy. 17 study days to complete STaM training were allocated to ensure compliance which also increased the need to fill vacant shifts. Alexandra Ward Midwifery staffing on Alexandra Ward is over establishment but during March there was one midwife supernumerary for orientation and one midwife on long term sickness. All shifts were put out to bank and agency as appropriate. There are currently vacancies in the band 2 and 3 post; although recruited into, staff have not started yet. 25 study days were allocated for March for the same reasons as Katherine Ward. Alexandra Ward staff were pulled at times to support the labour ward activity during times of high acuity and activity- although not ideal this is necessary when risk assessing. We hope to see an improvement in this over the next few months. Peter Pan Chris Mann, Nursing Services Manager, Paediatric Unit The figures for Peter Pan ward reflected a change in March to return to our regular non winter funded establishment of four qualified staff per shift. This occurred as a step down approach to our return to the normal establishment numbers from 1st April. This occurred only when the ward acuity permitted. The 97% fill rate for RNs reflects this approach. This percentage was complemented by the high percentage of care staff as during March two new RN starters were paid as HCAs as they had not yet received their NMC pin. Where high acuity did occur or 1:1 RMN specials were required these were requested but were easier to fill at nights than the day as represented in the elevated percentage rates. The 1 episode of sub-optimal staffing was where additional staff could not be resourced despite agency request. The continued high reliance on agency is reflective not only of the ongoing vacancies paediatrics currently has in nursing despite a pro-active recruitment campaign and the need to ensure high acuity patients receive the appropriate nursing intervention as identified in the RCN paediatric staffing guidance. 10
Surgery Medicine Appendix 1 STAFFING LEVELS March 2015 Data - April 2015 Report V1 Division Environment Ward Beds Average fill rate- RN /Midwives % Days Average fill rate- Care Staff % Fill Rates** Average fill rate- RN /Midwives % Nights Average fill rate- Care Staff % Temporary Staffing Reported concerns Bank hours Agency Sub -optimal hours**** staffing reported via datix Ald 19 106.3% 103.2% 166.1% 132.3% 1347.25 1001.25 3 1 2/0 100% B'east 20 84.1% 86.0% 100.0% 100.0% 909.25 408.67 1 3/1 92% 2 Bevan 24 103.5% 123.5% 103.9% 164.5% 1378.5 380 3/1 100% 1 CCU 7 83.9% 12.8% 100.0% 0.0% 542.75 200 1 100% Daniels 5 67.1% 87.4% 100.0% 183.4% 482 566.92 1 8/1 67% 1 Dray 18 99.7% 86.3% 100.0% 103.2% 390.67 229.24 2 2/3 89% 1 EAU/AMU 45 90.1% 102.3% 110.0% 102.2% 1160.5 4288.42 3 4/6 88% 4 Grange 30 91.0% 85.5% 115.3% 103.2% 944.5 1207.5 6 4 2/0 95% 3 Hayes 30 89.2% 109.4% 101.0% 146.7% 1094.5 98.5 4 2/3 88% 1 Stroke 20 91.8% 101.3% 94.6% 103.2% 489.67 604 1/1 100% Edmunds 29 102.7% 101.8% 100.0% 103.2% 400.5 1162 1 2/1 100% Pinewood 20 86.8% 108.5% 101.4% 241.9% 947.5 307 1 2 6/0 100% Lister 16 122.2% 108.4% 101.6% 190.3% 1053.75 844.75 1 2/1 100% 2 Churchill 20 126.7% 89.6% 104.5% 130.6% 1061.75 1050.79 2 1 6/1 91% 2 Jersey 30 85.3% 78.7% 111.8% 103.2% 1204.5 1075.92 1/0 95% 2 Kennedy 30 88.4% 73.4% 111.8% 106.5% 297.75 99 1 3 0/1 100% 1 ITU/HDU 9 71.7% 0.0% 87.5% 0.0% 997.75 415.25 1 1 Fleming 29 82.2% 80.0% 143.0% 101.6% 1504.5 2481.75 1/0 96% 2 Trinity 25 96.1% 85.2% 107.8% 161.5% 1813 1704 1 0/1 100% 1 Peter Pan 20 97.0% 106.5% 120.6% N/A 453.5 1079.83 1 3 NNU 20 65.9% 168.2% 71.9% N/A 123 0 Alex 22 80.9% 88.2% 96.8% 98.0% 507.25 49 9 1/0 83% Nurse Sensitive Outcome Indicators New PU Safety Thermometer Falls Safety Thermometer Kath 15 88.2% 83.7% 95.2% 90.3% 516.5 74.75 7 100% 2 Labour 13 78.6% 85.6% 98.3% 92.2% 737.75 570 6 83% 2 Hospital Acquired Pressure Ulcers*** Falls with no harm / Falls resulting in harm*** FFT % of patients extremely likely/likely Medication errors*** **E-rostering report, workforce report received 16.3.15 ***Incidents reported via datix **** Agency nursing by hours, information provided by temporary staffing office 11