SBAR REPORT MARCH 2010 FREE TO LEAD FREE TO CARE, EMPOWERING WARD SISTER / CHARGE NURSE SITUATION The purpose of this report is to inform the Board members of the current position and progress of Cwm Taf Local Health Board to the 35 recommendations required by Free to Lead Free to care, Empowering Ward Sisters / Charge nurses Ministerial task and Finish Group Final Report, June 2008. The report details the considerable progress Cwm Taf Local Health Board has made to recommendations via the following group structure and membership; Cwm Taf Free to Lead Free to care local steering group. Bi monthly meetings are Chaired by Executive Nurse Director, membership of this group includes a Non- Executive Director, Divisional Nurses, Heads of Nursing, Senior Nurses, Ward Sisters and Charge Nurses, Assistant Director of facilities, Patient Experience Manager and Clinical audit. Cwm Taf Ward Sister / Charge Nurse Forum Chaired by Senior Nurse Standards and Fundamentals of care, membership includes Ward Sisters / Charge nurses, representing all Directorates, Catering, Housekeeping and Estates Managers. Monthly meetings provide a forum for Professional and Clinical discussion and best practice BACKGROUND The Empowering Ward Sisters/ Charge Nurses Ministerial Task and Finish Group arose out of meetings between the Minister for Health and Social Services, the Royal College of Nursing and other staff and professional leaders within Wales.
They expressed concern about the patient experience, ward cleanliness, nutrition, infection control and general standards of care. Five work streams were identified; 1. Fundamentals of care All Wales Audit Tool Free to Lead free to care recognises the importance of the Fundamentals of care standards, (Welsh Assembly 2003) which had been included in the Plan for Wales as part of the Improving Health and social care services The Fundamentals of care 12 standards; Communication & information, Respecting people, Ensuring safety, Promoting independence, Relationships, Rest, sleep & activity, Ensuring comfort alleviating pain, Personal hygiene, appearance and foot care Eating & Drinking Oral health & hygiene Toilet needs Preventing pressure sores The Fundamentals of care (FOC) audit tool is a mechanism for evaluating and monitoring the quality and standard of patient care across Wales. The FOC audit is an annual audit that ensures that all care delivery is systematically monitored against standards. Nutritional Care pathway. The implementation of An All Wales Nutritional care pathway requires that all patients have a nutritional assessment undertaken within 24 hours of admission. This assessment is supported by the All Wales food and fluid charts. Patient nutritional care is a priority that is supported by the introduction of Protected meal times.
2. Ward Environment The ward environment captures many themes important to efficient and effective ward management; Enabling the ward sister/ charge nurse to have the authority to place patients appropriately, ensuring patients are not cared for in mixed bays and have appropriate designated toilet and bathing facilities. Visiting times Whether flowers should be permitted within ward areas 3. Environmental cleaning The highest standards of cleanliness must be maintained within all wards and departments. Collaborative working between Housekeeping and the ward sister / Charge nurse is fundamental to maintain clean wards and reduce hospital acquired infections. 4. All Wales Uniform An All Wales NHS Dress code and Nurses Uniform will be introduced across Wales by end 2010. 5. Education In order to support and properly empower ward sisters / charge nurses; all existing ward sisters / Charge Nurses should complete the approved empowering ward sister / charge nurse development programme and have their prior educational learning or experience accredited (APEL).
ACTIONS Ward Sisters / Charge nurses have developed and have ownership of the following Action Plan and are committed to the implementation, monitoring and review of each recommendation. 1 Implementing the Empowering Ward Sister/Charge Nurse Report Within each NHS Trust, the Executive Nurse Director should be responsible for the implementation of the Empowering Ward Sister/Charge Nurse Report and the Trust should appoint a non-executive Director to oversee and champion this process. An annual written update should take place to the Board until 2010 (the end of the timescale for implementation as set out in these recommendations). Free to Lead Free to Care Steering Group, a nominated Non- Executive Director and all Nurse Executives have responsibility for the implementation Bi Monthly Free to Lead Free to care steering group. Nominated Non Executive Director and Nurse Executive Chair. Monthly ward sister / Charge nurse forums Position Paper to Board April 09 Position Paper to Board April 2010
1. THE FUNDAMENTALS OF CARE RECOMMENDATIONS 2 Fundamentals of Care Ward Sisters/Charge Nurses should play a significant part in the updating of Fundamentals of Care (2003) in line with subsequent policy developments in particular the Health Care Standards. 3 Fundamentals of Care All Ward Sister/Charge Nurses should have access to an All Wales Audit Tool should be developed to measure standards against the Fundamentals of Care. Reports arising from this Audit Tool should be distributed to the NHS Trust Board and the Chief Nursing Officer, Wales. All hospitals are now undertaking a second Fundamentals of Care audit. The final reports will be presented at the first new LHB Board meeting and submitted to CNO by end of November 2009 All in patient wards completed All Wales FOC Audit Report presented to Board October 09 and Report sent to CNO Nov 09 Second FOC audit all in patient wards March 10. Departments / theatres / A & E / Paediatrics baseline audit May 10 4 Nutrition All Ward Sister/Charge Nurses should have access to an All Wales Nutritional Care Pathway to promote best professional practice in nutritional care throughout the NHS. Nutrition pathway in use All wards introduced Protected Meal Times
5 Nutrition/Hydration 6 Ward Sisters/Charge Nurses should play a substantive part in designing an All Wales standard fluid chart to be used across all NHS Trusts in Wales. All Ward Sisters/Charge Nurse should ensure that their ward staff are familiar with the national Intake/Output chart and incorporate it into their Induction Programmes. Nutrition All NHS Trusts should ensure that nutritional supplements are prescribed on drug charts and their administration recorded. All Wales Food & Fluid charts in use all wards 2. THE ENVIRONMENT OF THE WARD RECOMMENDATIONS 7 Mixed Gender Wards and Bays The Ward Sister/Charge Nurse should have the authority to decide on the placing of patients on the ward. Any ward that is mixed gender should be divided geographically and separate bathing / toilet facilities provided. The mixing of men and women in bays should not happen with the exception of Accident & Emergency Units, emergency admission units and critical care units. Exceptions to this policy should be reported and that data maintained for analysis (MB/EH/0696/09). All work associated with mixed gender wards will be addressed through the Free to Lead Free to Care Implementation Group. Meeting between, QSSID, Nursing, Capital Estates & Facilities to address issues in the HIW report. Agreed to enforce clear segregation bathroom facilities. Guidance / risk assessment areas unable to provide single gender bays- Stroke unit / Palliative care Assessment units / Day surgery All other areas compliant
8 Tasks of Health Care Support Workers The Ward Sister/ Charge Nurse should delegate clearly (e.g. utilising a rota system) any general cleanliness/tidying tasks that are the responsibility of Health Care Support Workers on the ward. Guidelines are being prepared, and will be issued to the Free to Lead Free to Care Implementation Steering Group for comment Procedure in place details roles & responsibilities for tidying & cleaning tasks. 9 Flowers Ward Sisters / Charge Nurses should have the authority to decide at an individual ward level whether flowers are allowed or not. This decision should be made based upon considerations around cleanliness or health and safety and not on misperceptions of hospital acquired infection. The use of disposable vases, sealed containers and oasis arrangements should be considered. The draft of guidelines has been sent to the Sisters/Charge Nurses Reference Group for final comments. It is anticipated that the final guidelines will be present for sign off at the next steering group meeting scheduled for November 2009. Ward Sisters / Charge nurses use their authority to decide whether flowers are allowed on their wards this is clearly communicated to patients and their relatives
10 Visiting Times The draft of guidelines has been sent to the Sisters/Charge Nurses Reference Group for final comments. It is anticipated that the final guidelines will be present for sign off at the next steering group meeting scheduled for November 2009 Ward Sisters / Charge Nurses should decide on appropriate visiting times for their ward and patients. Ward Sisters / Charge nurses use their authority to decide Visiting times on their wards this is clearly communicated to patients and their relatives 11 12 Storage To ensure access to bathrooms and other ward areas the storage of equipment, mattresses etc should be pooled centrally to reduce the amount stored at ward level. Communication with Patients Posters and leaflets should be designed to communicate effectively ward or hospital polices on issues such as the restriction of personal belongings, visiting times and flowers and ward sisters/charge nurses should take responsibility for ensuring their display and effective communication to individual patients, relatives and patient groups. This issue is being addressed through the Mixed Wards work (as above). Equipment libraries are being set up Transforming care to be implemented to all wards 2011, also addresses storage issues Think clean & tidy days Bedside patient information communication folders developed Posters developed detail flowers / visiting / personal belongings and use of mobile phones
3. ENVIRONMENTAL CLEANING RECOMMENDATIONS 13 Recommendation Cleaning Operatives Proficiency Certificate To ensure the ward sister/charge nurse is able to maintain the highest standards of cleanliness on the wards the NHS in Wales should adopt the Cleaning Operatives Proficiency Certificate award from the British Institute of Cleaning Science as the national minimum standard of training for ward cleaners. ALL WALES Progress A paper has been completed outlining options available to develop a sustainable approach in Wales. The paper to include an outline of costs. The paper is now with Mike Chown for consideration on the next steps CWM TAF Progress Await direction from FTL, FTC working group in case core training modules are identified. Core modules waiting agreement for the EWS Cleanliness group. Identified 10 modules in line with WAG identified core modules and are proceeding to implement COPC across Organisation. Training for assessors and trainers complete. Training of domestics to follow. 14 Standardising products for cleaning and infection control To support the ward sister/charge nurse role a national advisory forum, hosted by Welsh Health Supplies in association with Welsh Health Estates, should be established to review standardising products for cleaning and infection control across the NHS in Wales. This forum should also review new and innovative technologies for cleaning and infection control. Credits for Cleaning software purchased in line with FTL, FTC directive. Primary site (PCH) is utilizing audit tool in accordance with WAG directions. Work has commenced at the other sites and all will be up and running by March 2010 at the latest.
Recommendation 15 The National Standards of Cleanliness for NHS Trusts in Wales The National Standards of Cleanliness for NHS Trusts in Wales (2003) should be updated in line with subsequent policy and evidence based developments and the responsibilities of the ward sister/charge nurse should be made explicit and enhanced where necessary. Ward Sisters/Charge Nurse should be made aware of their responsibilities under these standards. ALL WALES Progress CWM TAF Progress 16 An all Wales monitoring tool for cleanliness To assist and support the ward sister/charge nurse in maintaining the highest standards of cleanliness in their wards an all Wales monitoring tool for cleanliness should be adopted across the NHS in Wales. Monitoring undertaken by the domestic supervisor should be signed off by the ward sister/ charge nurse.
Recommendation ALL WALES Progress CWM TAF Progress 17 18 19 Technical hygienists Consideration should be given to the development of new roles such as Technical Hygienists who are directly accountable to the ward sister/charge nurse in areas where there is a higher degree of clinical equipment e.g. critical care environments and orthopaedics. Specific Items Schedule Ward sister/charge nurses should be involved in the development of Trust wide schedules which clearly identify who is responsible for cleaning specific items of patient equipment. Assignment of Domestic Staff Regular domestic staff should be allocated to particular wards or work areas to enable them to work as part of the team. Day to day functional responsibility and accountability should be to the ward sister/charge nurse. Managed by Domestic Manager Completed This is an issue to be taken forward by each individual organisation. (It is anticipated that examples of schedules will be posted on HB / WHE web site so that best practice can be shared.) - Completed I t has been agreed that this is a HB issue and will be taken forward by each individual organisation Completed Housekeeping SLA and service model are currently being developed, and role profiles are being reviewed. Consideration to the achievement of this recommendation will be made as part of this work. Procedure identifies cleaning roles & responsibilities. Weekly infection & Environmental audits undertaken nursing staff Monthly infection & environmental audits undertaken joint Housekeeping & nursing staff Minimum weekly hand hygiene audits All wards have regular domestic staff allocated
Recommendation 20 Recruitment for Ward Housekeeper/Domestic staff The ward sister/charge nurse should be routinely involved with the recruitment process for the Ward Housekeeper/Domestic staff that will be allocated to their team. ALL WALES Progress As above CWM TAF Progress Ward sisters / Charge nurse are consulted 21 A Rapid Response Cleaning Service Every Trust should develop a stand-alone rapid response cleaning service, (in addition to the ward based cleaning team). Whilst the management of this service should remain a central function, ward sisters and the infection control team should be able to request this service and expect a response within a reasonable period of time dependant upon the nature of the request. This should include the ability to request deep cleaning following outbreaks, refurbishments and where standards have fallen consistently below the national standards. Guidelines on the role of such a team/service will be included in the revised Cleaning Standards document. It has been agreed that this is a HB issue and will be taken forward by each individual organisation - Completed Two Rapid response teams in place to cover North & South Hospital sites
4. All Wales National Uniform Policy Recommendation 22 An All Wales Nursing Dress Code To support the ward sister/charge nurse in maintaining high standards of personal/professional appearance in all ward staff an All Wales Nursing Dress Code should be developed and introduced across all NHS Trusts. 23 NHS Laundry of Uniforms The Welsh Assembly Government should undertake a detailed cost benefit analysis to determine whether an in-house NHS laundry process/system can be developed to support the introduction of the All Wales Uniform. 24 Availability of Uniforms All NHS Trusts should have stockpiles of uniforms to ensure their availability to nursing staff on a 24 hour basis. ALL WALES Progress The document is in its final stages of preparation. It will be presented to partnership forum before distribution to the service The Capital Facilities and Estates Division are working with Welsh Health Estates to prepare the brief for the scoping exercise. HB to provide procurement board with details of stock levels needed. Identification of storage facilities is a trust issue. - Complete CWM TAF Progress Await WAG guidance Await WAG guidance Information supplied to WAG via Cwm Taf uniform implementation group Uniforms expected delivery Sept 10
5. Education, Development and Support for the Ward Sister/Charge Nurse 25 Empowering ward sisters/charge nurse s Completed development programme In order to support and maintain a properly empowered ward sister/charge nurse workforce an All Wales approved empowering ward sisters/charge nurse s development programme should be established and places funded by the Welsh Assembly Government. This programme should address human resource and managerial skills and the maintaining of standards around issues such as cleanliness and nutrition/hydration on the ward. The programme is being piloted in ABMU LHB; the first cohort of 12 ward sisters will complete the course in January 2010. Currently undertaken scoping exercise related to numbers of Sister / charge nurses who are aspiring, newly appointed or experienced. Paper to Nursing & Midwifery committee Dec 09 to discuss options to deliver development programme 26 Empowering ward sisters/charge nurse s development programme As above As above All existing ward sister/charge nurses should complete the approved empowering ward sister/charge nurse s development programme and/or have their prior educational learning and/or experience accredited. (APEL). 28 Empowering ward sisters/charge nurse s development programme As Above As above Nurses who aspire to be ward sister/charge nurses should undertake the empowering ward sister/charge nurses development programme as part of their ongoing continuing professional development. This would be identified through their individual development plan under the Knowledge and Skills Framework.
29 30 31 Preceptorship All newly appointed ward sister/charge nurses should have a period of preceptorship of not less than six months from appointment. Supervision All ward sister/charge nurses should receive both managerial supervision as well as clinical supervision with clear lines of accountability to the Director of Nursing in place. Ward Sister/Charge Nurse Forum There should be a ward sister/charge nurses forum to develop peer support, learning, and information exchange. Chief Executives should develop a mechanism report of a record of this discussion maintained to communicate directly with this forum. The All Wales Professional Development Nurses Forum is undertaking this piece of work and will report progress at the next Steering Group See above Completed It has been confirmed that every LHB in Wales now has in place a Ward Sister/Charge Nurse Forum Await guidance steering group Await guidance steering group Monthly ward sister / charge nurse forum Recommendations Cwm Taf Local Health Board has made good progress towards recommendations and will continue to guide and empower the role of the Ward Sister/ Charge Nurse to ensure the basics of care are right. Patients need to feel safe, secure and cared for. Positive leadership motivates staff and results in an improved patient experience. The Board is asked to continue to give support to deliver and sustain the recommendations within Free to Lead Free to care and note the update provided. Rebecca Aylward Senior Nurse Standards and Fundamentals of care. March 2010