Author: Sponsor: Forum submitted to: Divisional Heads of Nursing Paper date: January 2018 Director of Nursing & Patient Experience Louise Stead Version: 1 Board January 2018 Paper ref: 9 1. Purpose of paper 1.1. Why is this paper going to board and what input is required? There is a national requirement to report to the board every 6 months on Nursing skill mix and patient. This report informs the Board on the Nursing and Midwifery staffing levels and whether they are adequately budgeted to meet the and dependency of patients and comply with the NICE SG1 Safe staffing for Nursing in adult inpatient ward guidelines and NICE Safe Midwifery staffing for maternity settings. It also includes information on the staffing reviews outside those two areas and the Care Hours per Patient Day audits recorded since February 2017 2. Executive Summary 2.1 Context: This report informs the Board on the Nursing and Midwifery staffing levels and whether they are adequately funded to meet the and dependency of patients. For continuity the same methodology has been used, using the Shelford patient tool and birth rate plus triangulation of national guidance and professional judgement. 2.2 Questions This paper addresses the questions: Are the adult inpatient wards appropriately funded to provide adequate nursing staffing levels? What additional Adult and Paediatic nurse staffing reviews have taken place and actions taken? Is the maternity service appropriately funded to provide adequate maternity staffing levels? Has the recommendations from the previous safe Nursing & Midwifery staffing board papers (July 2017) been implemented? What are the results of the Care Hours per Patient Day (CHPPD) audit? additional nursing staffing reviews are being undertaken across the Trust 2.3 Conclusion. This Board paper has demonstrated that the Trust has complied with the requirements to review Nursing and Midwifery staffing levels and report to the Board on a 6 monthly basis. With the exception of Compton all adult wards, paediatrics, maternity and departments have been found Pg.1
to have sufficient budget to provide adequate staffing levels. Budget setting for 2017/2018 has addressed the additional funding requirments to support safe staffing required on Compton. 3.0 The main report Rationale Determination of safe staffing levels in Nursing and Midwifery is complex due to a multiplicity of relevant considerations and their interdependency. National and professional guidance on has been taken into account, see appendix. 1. Any methodology must be tempered by professional judgement. Other factors taken into account include: Nursing a) National recommendations regarding nurse to patient ratio s, qualified staff to unqualified staff percentage. b) The use of specials. c) Acuity and dependency of patients and the trends in over the last six months. d) The harms sustained on the wards such as pressure ulcers, falls and the numbers patients. with CDifficile. e) The wealth of evidence-based research showing a direct correlation between higher numbers of qualified nursing and midwifery staff, and improved patient outcomes, improved recruitment and retention of nursing staff and economic benefits to employers and communities. Midwifery a) The Birth-rate Plus recommendations, a recognised workforce tool supported by NICE Safe Midwifery Staffing for Maternity Settings (2015). b) The case mix inclusive of risk factors c) The location of the activity, the level of activity and of mothers and babies d) The percentage of trained midwives versus maternity support workers on every shift e) Staffing level assessment across the whole of the service inclusive of community work f) Prioritisation of delivery suite in line with NICE intrapartum care guidelines (2007) g) Availability of trained midwives for emergency situations in and outside the maternity unit The midwife to mother ratio is currently set at 1:29 for the RSCH and 1:1 in labour. Determination of an appropriate midwife to mother ratio is further complicated by hour by hour variation in the level of activity and across the service. Professional judgement is applied by senior staff on a 4 hourly basis to ensure flexibility and meet workload demands 3.1 Are the adult inpatient wards appropriately funded to provide adequate nursing staffing levels? The table below compares the budgeted whole time equivalent (wte) with actual wte results from the patient audit. The Trust continuously performs daily patient audits. This paper includes the average patient results per ward over six months from July 2017 to December 2017. The data demonstrates different patient levels with peaks and troughs throughout the six months and across wards. This is managed daily by Matrons and Divisional Heads of Nursing, who triangulate all evidence with clinical judgement and re-deploy nurses across wards to match the of the patients. Where the tool does not include all potential patient risk factors specials are used to reduce the risk. The use of specials i.e: patients requiring 1:1 care on the wards for patients with dementia and acute delirium has reduced in some areas, due to the effectiveness of daily management review and the use of Pg.2
patient sitters. The overall use of specials between July and December has increased by 0.27% compared the period January 17 to July 17 as some wards experienced significant numbers of patients at risk of falls, confused and wandering patients, patients under Deprivation of Liberties (DOLs), mental health patients requiring the care of Registered Mental Nurse (RMN) and patients with tracheostomies and non-invasive ventilation. 3.1.2 Wards This table shows the budgeted wte, average patient, compliance to RCN guidance and NICE guidance.the average use of wte specials uses on wards. (Specials data is calculated; is calculated as total hours divided by 6 (months) divided by 162.95 (hours that 1 would work per month) Table 1 Ward Budgeted wte 6 month average patient diff Highest overall in 6 months Lowest overall in 6 months Average specials used monthy Jan Jun 2017 Average specials used monthy July Dec 2017 Budgeted complain ce with 65%/ 35% RN/HCA ALBURY 43.26 38.91 4.3 39.96 33.27 1.9 +1.47 71%/29% 1RN:8Pts ratio Day Night 1:6.5* 1:6 1:7.5 1:10 1:6.3* 1:6 1:7.5 1:10 1:5 1:7.5 1:10 1:7* 1:10 41.12 1.75-1.78 65%/35% 1:5 1:7.5 1:6 1.25 +0.51 67%/33% 1:5 1:5 BRAMSHOTT 35.67 31.57 4.1 33.30 29.57 0.28-0.36 60%/40% CLANDON 29.90 23.06 6.84 24.55 20.23 1.51 + 0.45 59%/41% COMPTON 36.1 36.55 0.45 40.26. 31.97 0.19-1.13 70%/30% EASHING 43.35 44.2 0.85 46.14 44.43 1.3 + 0.32 64%/36% **ELSTEAD 23.85 21.64 2.21 22.55 21.06 0.29-0.35 57%/43% EWHURST 38.71 39.95 1.24 41.35 36.42 4.06-4.75 60%/40% FRENSHAM 35.60 37.65 2.05 39.38 35.60 2.73 +3.31 70%/30% HINDHEAD 41.68 42.66 0.98 44. 34 MERROW 31.24 31.87 0.63 33.64 29.83 0.28-1.85 61%/39% MILLBRIDGE 30.53 34.16 3.61 40.83 30.47 2.37-2.39 61%/39% ONSLOW 46.60 45.38 1.22 47.26 42.32 0.37-1.55 60%/40% WISLEY 41.85 38.41 3.44 42.11 32.3 *average for RN: patient ratio, as different numbers of RN s on duty early and late shifts - exclusion of nurse in charge on day shifts (NICE) **Tilford patients and staff transferred locatction to Elstead ward in Novemeber 2017. Albury: continues to care for non-invasive ventilation level 2 patients and specials were utilised to maintain patient safety the use of specials increased between September and December, this is managed by the ward sister and the matron. The increase in level 2 patients seen between Pg.3
Setember and December is consistant with the seasonal variation of the winter months when the ward see s an increase in patients requiring respiratory as in level 2 patients. Clandon: provide a 24 hr emergency ENT clinic in the ward, staffed by 1.0 wte HCA Monday - Friday between 8am and 4pm; out of hours and at the weekend the ward staff absorb the clinic work load alongside inpatient care and undertake the first patient specialing from their establishment. The daily tool used does not effectively weight the nursing requirments of Head & Neck patients and is supported by professional judgement of the matron and the DHoN when there was a the requirement for specials to support patients with tracheostomies. Elstead: In December 2017 Elstead ward was reconfigured from a diabetes and endocrine ward to a short stay older peoples unit as part of the development of the Trust s acute frailty pathway. The table below shows the data from the last 6 months. Unlike previous reports there is a consistantly in high in the month of January. Tilford moved into Elstead on 1 st November, for the purpose of this paper it is all known as Elstead Table 2 Shalford tool provides RN & HCA data and the results are detailed below WARD Wte RN's 6 Wte 6 in month Highest Lowest HCA's month average average budget in RN RN RN budget HCA Highest HCAs Lowest Acuity HCAs ALBURY 30.85 23.54 26.82 17.88 12.41 15.66 17.88 14.09 BRAMSHOTT 21.56 18.69 20.78 13.86 14.11 12.46 13.86 11.29 CLANDON 17.67 13.83 14.73 9.82 12.23 12.14 9.82 8.9 COMPTON 25.47 21.92 24.16 16.1 10.63 14.55 19.18 12.79 EASHING 28.02 25.68 26.59 17.73 15.33 17.34 17.64 16.6 **ELSTEAD 13.71 12.98 13.55 12.64 10.14 8.62 9.02 8.42 EWHURST 23.09 23.04 26.9 17.22 15.46 15.98 21.81 14.57 FRENSHAM 24.98 22.59 23.09 15.75 10.62 15.06 21.36 14.25 HINDHEAD 26.18 25.66 26.6 24.67 15.50 16.79 24.67 15.75 MERROW 19.29 19.12 20.18 18.04 11.95 13.12 17.9 11.93 MILLBRIDGE 18.86 20.49 24.5 18.28 11.67 13.66 16.33 12.19 ONSLOW 27.84 27.31 28.36 25.93 18.76 18.15 18.09 16.93 WISLEY 28.04 23.04 25.26 16.84 13.81 15.36 16.84 12.92 Over 6 months H=highest L=lowest H=Nov L=July H=Sept L=Oct H=Sept L=July H=Nov L=July H=Sept L=Dec H=Dec L=Sept H=Sept L=Aug H=Nov L= Dec H=Dec L=July H= July L=Dec H=Dec L= Aug H=July L=Oct H=Oct L=Dec The following departments: Intensive Care Unit, Emergency Department, Coronary Care Unit, Day Surgery Unit, Surgical Short Stay Unit and Outpatients department (OPD) staffing has been reviewed against National & Professional guidance and clinical judgement and are found to be adequately funded to provide the staffing required in the following departments; Pg.4
Patients on PAU at 20:00, or admitted out of hours NURSING AND MIDWIFERY STAFFING LEVELS The Emergency Assessment unit (EAU) is completing the Shelford Acute Assessment Unit audit in January 2018 the results of this audit will be presented in a paper to board in March 2018 3.2 What additional Nurse staffing reviews have taken place and actions taken? Hascombe Nurse staffing levels for Hascombe ward are based on the RCN s standards for clinical professionals and service managers Defining staffing levels for children and young people s services (2009). A full staffing review has been conducted in line with these recommendations and this has shown there is a requirement to increase staffing of its Paediatric Assessment Units (PAU). This is in response to winter pressures associated with increased clinical where the current ward staff are unable to absorb PAU activity outside the current opening hours of 8am to 8pm Table 3 shows a typical month of PAU activity after 8pm when there is no allocation of designated nursing staff Table 3 November 10 9 8 7 6 5 4 3 2 1 0 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th Numbers 2016 5 7 4 2 5 7 4 5 6 6 6 4 3 7 3 5 4 8 8 8 0 5 6 6 8 4 6 5 4 3 Numbers 2017 7 4 8 2 3 8 7 6 5 6 3 6 4 6 8 2 3 5 6 5 2 2 3 9 3 6 8 8 3 5 There are on average 4.86 children seen in PAU after 8pm. Analysis of the length of stay has further identified that the majority of children stay for 3 hours and are then discharged home or are admitted to the ward by midnight. During summer this activity is managed well by the existing nursing team due to seasonal variance however during winter (October to end February), the of children is much greater and as such the staffing levels for inpatient children may be negatively impacted. The existing pressures on PAU are further impacted by the flow of maxillofacial attendances from other hospitals for minor treatment such as repair of lacerations and removal of foreign Pg.5
bodies. On average 2 children are directed to Hascombe ward at 7am each morning to be reviewed by the RSCH Max Fax team. This adds further workload to the existing nursing workforce and as such requires further consideration. Appraisal of current staffing has identified a need to increase the staffing for PAU by 0.4wte (annualised) to support the existing skill mix and to maintain safe staffing for the ward. The opening hours for PAU will change from 0800hrs 2000hrs to 07.00 hrs to midnight. This change will be managed through reconfiguration of the current nursing workforce within existing budget. Special Care Baby Unit (SCBU) Staffing levels for Neonatal care is monitored against the Department of Health Neonatal toolkit (2009) and the British Association of Perinatal Medicine Guidelines (2013) and current staffing is flexed according to meet the categories of care for babies. At times when is higher than planned staffing levels the nursing team follow a clear escalation plan to ensure appropriate ratios. The senior team including the SCBU manager, Matron and Clinical practice development sisiter works clinically when required to support patient care. There were no red staffing flags reported from July to December 2017. A further staffing review is in progress in response to new neonatal network guidelines as the requirement is that all babies less than 32 week babies must be transferred to level 2 or level 3 Neonatal Intensive Care Unit s (NICU). There is now a need to assess the configuration of cots based on these criteria with a resultant workforce review to demonstrate appropriate staffing. The Chief of Service is currently reviewing cot numbers and the Divisional Head of Nursing (DHoN) and matron will review nursing staffing levels accordingly and will present a paper to clinical executive committee with their findings prior to the staffing board paper in July 2018. Wisley & Millbridge Ward Wisley Ward provides acute stroke care for Guildford and Waverly patients, patients repatriated from Frimley Park Hospital. Ward based therapy for these patients is crucial to their recovery to support the rehabilitation of patients. The gym area required to support patient rehabilitation has moved to Wisley ward from Millbridge ward in order to provide this care in a more efficient way. This move has resulted in the closure of 6 beds on Wisley ward and the opening of six beds on Millbridge ward. In order to safely staff this new bed configuration the following changes to staffing from Wisley to Millbridge Ward s nursing establishments: Table 4 Millbridge Wisley RN adjustment Increase 3.86 RN Decrease 6.82 RN HCA adjustment Increase 3.14 HCA Decrease 0.53 HCA Original pre changes. 30.03 wte 40.85 wte Current : 37.03 wte 34.56 wte Pg.6
Allowing each ward to run the following staffing numbers: Table 5 Ward Previous Rota Current Rota Budgeted 65%/ 35% RN/HCA Millbridge Ward LD: 4+3 N: 3 + 2 LD: 5+4 N: 4+2 55%/45% Wisley Ward LD: 6+4 N: 5 + 3 LD: 5+3 N: 4+2 62%/38% 1RN: 8Pts ratio Day Night 1:7.5 1: 10 1:7.5 1: 10 The establishment adjustment does not result in any additional costs to either ward and the move has enables the stroke gym to be co-located within the stroke ward. This has resulted in an improved patient experience for the patients of Wisley ward Compton ward: Following closure of Elstead ward on July 1 st 2017, there was a need to review the skill mix of staff on Compton ward. The staff began caring for the following speciality patients; Gynaecology, Breast, Urology and Colorectal surgery. To support all groups of patients a skill mix review was undertaken by the Matron and the DHON to ensure relevant expertise for all speciality patients. This supported the safety of patients, the training needs of staff and increase flow through the ward. Patient was reviewed daily. The additional investment required to support the new staffing model was 3.57 wte trained staff. The changes were implemented on Compton Ward from the July 1st 2017, with Executive agreement it is anticipated the stffing be incorporated in the 2018/19 budget to staff Compton if requirements remain unchanged following the 6 monthly audit. Since July 2017 Compton ward has seen significant changes to patient speciality, transitioning from a two speciality ward to a four speciality ward. The ward now focuses its care supporting Urology, Colorectal, Surgical Gynaeoncology, Gynaecology and Breast patients. Compton ward is now growing into a dedicated Pelvic Centre of Excellence with a supported patient pathway for major breast surgery. The investment in July was originally planned to come from closure of Elstead ward & the Transformational CIP saving. Following discussions with finance and the division the increase to Compton staffing was supported part year effect from the surgical nursing underspend. The tables below show the budgeted whole time equivalent (wte) against the wte results on the completion of the patient audit July 17 to Jan 18 and compares this to the previous six months. Compton ward continues to perform daily patient audits and this paper provides a more comprehensive average over six months. The additional investment required to support this staffing model was 1.37 wte trained staff which was funded for 6 months from the surgical nursing underspend. Since the closure of Elstead in July 2017 and the amalgamation of both Elstead and Compton ward, it can be demonstrated that the in and the flow of patients through the ward now requires an overall increase in staffing of 1.37 wte trained staff and 2.2 wte health care assistants. Table 6 Shows the data from the last 6 months July 2017 to January 2018 compared to January 17 to July 17. This data highlights the increase in RNs and HCAs, at the highest and lowest points in this period. This table shows the budgeted wte, average patient, compliance to RCN guidance and NICE guidance, compared with the previous 6 month period. Pg.7
Table 6 WARD COMPTONcurrent wte staffing Budgeted 6 month Average Patient diff Highest overall in 6 months Lowest overall Acuity in 6 months Specials used in 6 months Budgeted Compliance with 65%/35% RN/HCA 36.1 36.54.53 40.26 31.97 + 1.13 70/30% 1 RN:8PTs Ratio Day** Night 1: 6 1:10 COMPTON wte pre July 2017 34.73 30.07 4.66 31.49 29.29-0.19 65%.35% 1:7.5 1:10 The table 7 shows the data from the last 6 months July 17 to January 18 compared to January 17 to July 17. This data highlights the increase in RNs and HCAs, at the highest and lowest points in this period. Table 7 WARD Wte RN's in budget 6 month average RN Highest RN Lowest RN Wte HCA's in budget 6 month average HCA Highest HCAs Lowest Acuity HCAs COMPTON JAN 2018 25.47 21.91 24.16 19.18 10.63 14.6 16.10 12.79 Over 6 months H=highest L=lowest H= Nov L=July COMPTON PRE JULY 2017 22.73 18.88 21.4 17.58 12.0 11.78 13.4. 9.45. H=Jan L= April Table 8: Compton ward staffing comparison pre & post Elstead ward closuremptow rota NighRota RN ratio toatients Compton wte Changes to RN wte HCA wte Day rota Night rota RN ratio to patients Budgeted wte 2017/18 34.73 N/A 22.73 12 Early 5+3 Late 5+3 3+2 1:7.5 Day Budgeted compliance with 65%/35% RN/HCA 1:10 Night 55%/45% Current Rota with change in skill mix 36.10 17/18 6 months 1.37 25.47 10.63 Early 6+2 Late 6+2 3+2 1:6 Day 1:10 Night 66%/44% Total requested staffing increase for 2018/19 39.32 18/19 4.59 25.47 13.85 Early 6+3 Night 6+3 3+2 1: 6 Day 1:10 Night 66%/44% Pg.8
The flow of patients through the ward is considerable and the number of admissions and discharges from Compton ward has significantly increased since July 2017 with trained staff now admitting and discharging between 9 & 16 patients every day. This takes up a considerable amount of nursing time and these admissions and discharges are not fully accounted for in the patient daily. The Shalford tool allows 9% of bed numbers for admissions and dischragescurrently Compton has between a 30% to 50% discharge and admissions rate. 3.3 Is the maternity service appropriately funded to provide adequate maternity staffing levels? Between July and December 2017 the maternity service was funded to provide a midwife to mother ratio of 1:29. This calculation is based on analysis of the previous six months activity and as per the NICE endorsed Birth-rate plus methodology. In brief this means that the maternity service required one whole time equivalent midwife for every 29 women booking to have all of their care provided by the RSCH. Table 9 demonstrates the actual (1:30.09) position between July and December 2017. A further calculation is included to show how the use of temporary midwifery staff positively supported the vacancy factor during the time period (Table 10). Table 9: Midwife to Mother Ratio based on established posts including vacancies versus birth numbers Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Average over 6 months M:M ratio 30.49 26.69 32.33 33.30 32.44 25.3 30.09 (December was a low birth month 214 women with new midwife starters included into the midwifery numbers. Table 10 : Ratio based on establishment and amended to include temporary staffing Time Period 1 st July 2017 31 st December 2017 Planned Midwife to Mother Ratio Substantive in post Midwife to Mother Ratio Midwife to Mother Ratio inclusive of temporary staffing 1:29 1:30 1:29 Acuity of Women This is an important consideration when determining safe staffing as funding for maternity services should not be based on birth numbers alone as recommended by NICE guidelines (2015). The of women is categorised in accordance with the Birth-rate Plus Clinical Factors Outcome of Labour and Delivery tool. Category 1-3 contain lower risk women, categories 4 and 5 contain high risk women who require additional specialist midwifery input during the antenatal, intrapartum and postnatal periods. Data is sourced from the electronic maternity information system E3 and 100% of deliveries were captured. Table 2 and 3 shows the impact of over an 18 month period. Table 11: Changes in over last 18 months. Time period Percentage of women who fall into Birth Acuity categories 1-3 (low risk) Percentage of women who fall into Birth Acuity categories 4-5 (high risk) 1 st January 2016 30 th June 2016 51.1 48.9 1 st July 2016 31 st December 2016 40.4 59.6 1 st January 2017 30 th June 2017 31.5 68.5 1 st July 2017 31 st December 2017 35.0 65.0 Pg.9
Percentage NURSING AND MIDWIFERY STAFFING LEVELS Table 12: Complexity of Case mix The graph demonstrates that the previous increase in the complexity of obstetric cases has marginally decreased. Table 13: The impact on clinical care and patient safety 97 1:1 Care in Labour 96 95 94 1st January 2016 30th June 2016 1st July 2016 31st December 2016 1st January 2017 30th June 2017 1st July 2017 31st December 2017 Over a 24 month period, the midwife to mother ratio for 1:1 care in labour rate has increased from 94.5% to 96.6%. Where women do not receive one to one care from a midwife, escalation measures are implemented to support patient safety monitored by the matron team. 3.3 Have the recommendations from the previous safe nursing staffing board Papers (July 2017) been implemented? All recommendations from the previous Board paper have been implemented as of July 2017 Table 14 Ward To which ward Investment 1.37 wte band 5 Compton Investment 0.48 wte band 2 Frensham Pg.10
3.4 What are the results of the Care Hours per Patient Day (CHPPD) audit? The population of the model hospital with real data is behind schedule, making benchmarking a challenge however RSCH is committed to complete this exercise and has benchmarked the Trust s CHPPD against other providers where we can. (The CHPPD data is submitted to Unify monthly and displayed on the Trust website, along with the Nursing and Midwifery staffing.) All ward matrons have undertaken a review of the CHPPD data from individual ward and compared it to the data of other hospital with similar wards i.e. numbers of beds and specialities. A limitation of CHPPD comparison is that wards across the country do not have the same number of beds or speciality mix. For example as described earlier in this paper, Compton ward is unusual with its four different specialities and the majority of its work being cancer readily highlights the challenges and limitations in undertaking a true comparison 4.0 Conclusion: This Board paper has demonstrated that the Trust has complied with the Francis Report and Chief Nursing Officers requirements to perform a patient reporting to the Board on a 6 monthly basis. This audit has been triangulated with national guidance and clinical judgements. Nursing will continue to review staffing levels and patient on a daily basis and re-deploy or utilise specials to maintain patient safety. (With the exception of Compton ward all adult wards have been found to have sufficient budget to provide adequate staffing levels.) Additional staffing identified to support Compton and Elstead with be supported through the business planning planning process of Medicine and Surgical triumvirate. Daily staffing & patient audits are embedded in practice and managed well by the senior nursing team. They will continue to review and adjust staffing on a daily basis to maintain patient safety SCBU and Hascombe ward have sufficient budget to provide adequate staffing levels, however due to increased activity in PAU, a skill mix review will support the required changes to Hascombe paediatric assessment unit and this will be managed within budget. Maternity staffing levels are monitored using Birth-rate plus as endorsed by NICE. There is sufficient budget to provide appropriate staffing at a ratio of 1:29. The findings of the one to one care in labour audit shows resources are being optimised to support service provision with continued improved levels of care in labour. Pg.11
Appendix 1 The following guidance has been taken into account for this Paper Area Recommending Body Guidance Midwifery Stroke General wards Hascombe childrens ward Royal College of Midwives NICE -Safe Midwifery Staffing for Maternity Settings (2015) Royal College of Physicians National Clinical Guidelines for Stroke(2012) Royal College of Nursing Mandatory Nurse Staffing Levels(2012) Safe Staffing for Older Peoples wards(2012) Setting Appropriate Ward Nurse Staffing Levels in NHS Acute Trusts(2006) NICE- Safe staffing for nursing in adult inpatient wards in acute hospitals(2014) Royal College of Nursing Registered Childrens Nursing standards for clinical professionals and service managers Defining staffing levels for children and young people s services (2009). Midwife to mother ratio 1:28 adjusted for local population currently = 1:29 90% midwife to 10% MSW Band 3 skill mix HASU patients 80%RN/20%HCA, + 2.9 nurses per patient. Stroke patients 65%/35%+ 1.35 nurses per patient 65%RN/35% HCA skill mix Inpatient ratio Ideal, good quality care is 1RN:5 patients 1RN:7 patients Minimum 1RN: 8 patients day shift (excluding nurse in charge) General wards Carter report 2016 Care Hours Per Patient Day The CHPPD calculation was implemented nationally following the Carter Report (2016). It divides the number of actual nursing (registered and unregistered) hours by the number of patients at 23.59 pm each day. It is the number of nursing hours that available to each patient. There is no formal target which states what CHPPD should be, however the range of CHPPD Lord Carter suggested was 6.3 to 15.5. Pg.12