TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST Report to Public Trust Board meeting of the 25 th May 2017 Agenda Item 7b Title Sponsoring Executive Director Author (s) Purpose Previously considered by Safe ing Report Tracey McErlain-Burns, Interim Chief Nurse Tracey McErlain-Burns, Interim Chief Nurse To note/receive n/a Executive Summary In-line with the Hard Truths Commitments regarding the publishing of ing Data, the Trust Board are required to review staffing data on a monthly basis. The challenges associated with achieving safe staffing levels are well understood by the Board. Registered Nurse fill rates are low at 90.2%, supported by care support worker rates in excess of 100%. Three wards are consistently featuring in the list of those with fill rates <80% and this month specific action has been taken in relation to protecting Registered Nurse input to ward 42. Using the NHSI Model Hospital Dashboard it is apparent (based on January 2017 data) that the ICFT CHpPD is similar to 50% of other organisations. A review of School Nursing and Health Visiting is taking place within the respective Division; both services experiencing increased demand following the publication of the Ofsted Report in Tameside. Finally, the Board should note that an open recruitment day is scheduled to take place on 10 June with a further day planned (if required) for 01 July. In preparation for these events, new recruitment materials are being produced including a video that features services across the ICFT. Related Trust Objectives Risk Assurance risk impacted upon Legal implications/regulatory requirements Financial Implications 1 1. All patients receive harm free care through the Trust s Patient Safety Programme. 2. To improve the quality of patient care through the implementation of the Trust s agreed Quality Strategy. 3. To improve the patient experience through a personalised, responsive, compassionate and caring approach to the delivery of patient care. CR734: Nurse vacancies, leadership and nurse staffing/ recruitment across medicine and the ability to provide safe care. AF3480: Failure to meet CQC registration requirements relating to staffing. AF3482: Failure to ensure adequate staffing levels to ensure patient safety and quality of services NHS England monthly requirement to publish and report ing Data The CQC report published 7 th February 2017 states that the Trust must ensure that there are appropriate numbers of nursing staff deployed to meet the needs of patients (medical services). There are no new immediate financial implications albeit the financial implications of international recruitment are being considered by the executive team.
Has a quality impact assessment been undertaken? How does this report affect Sustainability? Yes where applicable in plans The Trust is required to ensure staffing levels are adequate to meet patient safety and quality requirements. Action required by the Board The Trust Board is requested to receive this update and note the actions described and the assertive monitoring and management in place. 2
Background This is a monthly report to the Trust Board following National Quality Board (NQB) guidance issued in November 2013 to optimise nursing, midwifery and care staffing capacity and capability: How to ensure the right people, with the right skills, are in the right place at the right time: A guide to nursing, midwifery and care staffing capacity and capability. The guidance clearly sets out the expectations and requirements of the Trust to meet the Hard Truth s commitments (following the Mid ordshire report). In July 2016, the NQB published an updated set of expectations for nursing and midwifery staffing to assist NHS Provider Boards to take local decisions which will deliver high quality care for patients within the available staffing resource (Supporting NHS providers to deliver the right staff, with the right skills, in the right place, at the right time Safe sustainable and Productive ing, NQB, July 016). This updated guidance incorporates Lord Carter report findings, in setting out the key principles and tools that provider boards should use to measure and improve their use of staffing resources to ensure safe, sustainable and productive services. As advised in recent months the content of this report is evolving to ensure that the Board has a complete picture of matters relating to safe nurse staffing. This report includes the position regarding school nursing and health visitor staffing. Safe ing Update April 2017 Data Each month the data collection compares the number of nurse staff hours Planned against the number of nurse staff hours used Actual. This is collected by ward, by shift, and is reported by calendar month as a % fill rate by day and by night. Please refer to the heat map (Appendix 1). This staffing information is published via NHS Choices. This data is currently available via our public website in a specific designated section Safe ing : (www.tamesidehospital.nhs.uk/nursestaffing.htm) Overall, Registered Nurse (RN) fill-rates remain constant (with minimal change) month on month, but unregistered (Healthcare Support Worker) fill rates fluctuate due to levels of enhanced care required (1:1 s) and additional support for RN shortfalls. The following graph highlights to the Board that unregistered fill rates for day and night shifts usually meet or exceed 100% and registered fill rates for night shifts have maintained consistency of over 95%. Senior Nurse leaders review nurse staffing levels (actual against planned) several times a day and a conscious decision has been taken to increase the levels of fundamental care support by unregistered staff when registered nurses are not available to fill shifts. The registered nurse fill rate for day shifts is currently running at 90.2% which demonstrates minimal improvement in comparison to the rate of 89.9% for the month of March. The details in this report describe some of the actions being taken to address the shortfall. The reasons for the slight improvement are tighter roster controls specifically with regard to annual leave. 3
% Fill Rate 120 115 110 105 100 95 90 85 Nurse & Midwifery ing - Average Fill Rates Registered % of shifts filled DAY Registered % of shifts filled NIGHT Health Care Asst % of shifts filled DAY Exception Report April 2017 There were 3 inpatient areas with registered nurse/midwife fill rates <80% in April 2017 (Appendix 1 heat map). Those areas were: Ward 42 Ward 44 Ward 46 Wards 42, 44 and 46 continue to be featured in this section of the board report as they continue to have a fill rate of less than 80%. The current registered nurse vacancy factor on Ward 42 is 6.76 wte, for Ward 44 it is 3.9 wte and Ward 46 remains at 5.29 wte. All three areas have bespoke adverts currently out and are proactively engaged in the Trust registered nurse recruitment day. In addition all 3 wards are recruiting a fixed term Band 3 Care Co-ordinator role as part of changes to their models of care. The band 3 role has proven to be very successful in other medical ward environments in supporting patient flow and overall ward co-ordination. As agreed with the Board in April, further details in relation to the focus on safe staffing within the medical wards will be reported to the Board in June 2017. Since February 2017 this report has included details of the number of escalation beds open and the impact on nurse staffing. In the month of April there was an average of 13 additional beds opened across ambulatory care, the day care unit, surgical unit and the heart care unit 1. Temporary nurse staffing totalling 425 hours (a combination of registered and unregistered) was requested of which 230 hours were filled via NHS Professionals and the remaining hours were redeployed from other areas within the Trust. Filled / Worked % Filled Requested Unfilled Ambulatory Integrated Assessment Unit 50 24 26 48% Surgical Unit 13 13 0 100% Ward 30 H C U 100 48 52 48% Day Surgery Unit 225 110 116 49% Total 388 195 193 50% 1 An increase of 8 on the average number of escalation beds open in March 2017 4
Care Hours per Patient per Day (CHpPD) In recent months the heat map attached at appendix 1 has included actual CHpPD; a measure used by NHS Improvement. This provides a consistent way of measuring the deployment of nurses and healthcare support workers and it needs to be used alongside acuity and skill mix. Planned CHpPD by ward and Trust has been added to the heat map from February 2017 to show the hours required (based on nurse staffing establishments) versus that available. This month s heat map draws attention to six wards with actual registered CHpPD hours less than planned. All six areas demonstrate that they backfilled the shortage of registered nurses with unregistered staff as their actual unregistered CHpPD hours are more than planned. Of note, Ward 40 had additional support in month of 275 hours of Band 7 Physiotherapy time working alongside nursing staff on day shifts and these care hours are not included in the CHpPD calculation in line with NHS England requirements. The heat map also draws attention to areas such as critical care, the neonatal unit, children s unit, Stamford Unit and Shire Hill all of which exceeded their planned RN hours. This was due to reduced occupancy in those areas at times during the month of April, for example occupancy in the critical care unit for the month was 67%. The graph below shows the trend in actual CHpPD, as a total of days and nights, registered and unregistered, since the methodology was introduced. 7.8 7.6 7.4 7.2 7 6.8 6.6 6.4 6.2 6 7.5 7.0 7.2 7.1 CHPPD Trust Total 7.7 7.3 7.0 7.0 7.5 7.2 6.7 7.5 6.6 7.4 6.5 CHPPD Total Planned Benchmarking data is now available via the NHS Improvement Model Hospital Dashboard and the graph below shows the Tameside and Glossop CHpPD vs the national average. The Board should note that the Model Hospital data is January 2017. The first of the two graphs below represents CHpPD for Tameside and Glossop compared with the national median. The axis on the left ranging from 6.9 hours to 7.9 hours; with over 30 mins difference between the Tameside and Glossop Integrated Care NHS Foundation Trust and the national median between June 2016 and October 2016. The second graph shows the Trust position set against the national distribution. This metric does not speak to what levels of nurse staffing are right or wrong, as indicated above it needs to be reviewed alongside acuity and skill mix analysis. 5
Safe Midwifery ing As described in last month s paper work is still on-going to support the development of the new A- EQUIP model of non-statutory midwifery supervision. The Head of Midwifery will present the proposed new model to board in June 2017. Community Nursing (adult) As advised last month a capacity and demand exercise is underway to inform our understanding of the caseloads being managed by our community nursing teams. The teams are currently fully recruited to establishment however there are 4.0 colleagues due to leave the service shortly and therefore recruitment is being advanced and some fixed term agency support has been secured. In line with the NHSI consultation paper on safe community nurse staffing the Assistant Chief Nurse (Medicine) has commenced a piece of work to review community nursing specific red flags / canary markers and an update on this will be included next month. 6
Children and Young People A must do action in the Care Quality Commission (CQC) report is to ensure that there is one nurse on duty on the children s ward trained and up to date in Advanced Paediatric Life Support (APLS) on each shift. As reported last month, this requirement has been met. Health Visiting In February 2011 the Department of Health launched the Call to Action Health Visitor Implementation Plan. This plan sought to increase Health Visitor numbers to pre-1990 levels, increasing capacity to modernise the public health agenda and work with children and families. The number of Health Visitors in Tameside at the time was 31wte. Based on the target set by the Department of Health at the time Tameside was to increase its establishment of Health Visitors by 48% based on population size and deprivation indicators to achieve an establishment of 59.3wte. There are currently 54.1wte Health Visitors in post however it is known that 4.7wte plan to leave / retire in the next few months and there are 4.2wte on maternity leave. The service is recruiting to vacancies and risk mitigation plans are in place to manage the impact of vacancies / leave on achieving the Health Visitor requirements of the Healthy Child Programme. School Nursing The Call to Action for School Nursing Services was launched in March 2012 by the Department of Health. This described the School Nursing ambitions within the Healthy Child Programme which focuses on children from the age of 5 to 19 years. The School Nursing service in Tameside covers a population of 34,220 children and young people within 15 secondary schools, 75 primary schools and 5 special schools. The total population of 5-19 year olds is approximately 42,000. The Call to Action recommended one specialist qualified School Nurse per secondary school which has not been achieved in Tameside. The School Nursing establishment includes 8.57wte specialist, qualified School Nurses working with Nurses, School Health Assistants and some specialist nurses. In common with other services across the country, the impact of the recent Ofsted Report has led to increased safeguarding activity for both the Health Visiting and School Nursing Service. A review of both services is currently underway and an update will be provided to the Board in July 2017. Red Flags There were a total of 54 incidents with 147 Red Flags recorded via the incident reporting system with regard to Nurse ing for April 2017 this is due to the fact that multiple red flags can be reported for one incident. The number of red flags recorded can be broken down as shown in the graph and table on the following page. The table below captures that the number of incidents and red flags in month compared with previous month(s). March 2017 April 2017 No of Incidents 69 54 Red Flags 163 147 7
Department A shortfall of more than 8 hours or 25% of Registered Nurse time available Delay of 30 minutes in providing pain relief Intentional rounding Less than 2 registered nurses present on a ward during any shift Missed breaks Patient vital signs not assessed or recorded as outlined in the care plan Unplanned omission in providing medication Ward 41 9 6 9 13 1 2 42 Ward 42 15 15 5 12 10 1 58 ACU 3 1 4 4 1 13 AMU 1 3 4 Ward 31 3 2 2 3 2 12 Dewsnap Clinic 2 2 4 IAU 3 1 1 2 1 9 A&E 1 1 Surgical Unit 1 1 1 1 1 5 Hollingworth Clinic 1 1 Ward 45 1 1 Grand Total 38 27 21 0 41 15 5 147 Total It is essential that nursing and midwifery leaders review any trends in relation to Red Flags. Specifically this month, based on the April data, the Assistant Chief Nurse (Medicine) has been ring fencing three Registered Nurses per shift on Ward 42 given the shortfall of 8 hours or more nursing time reported and the omission of vital sign recording. The impact of this will be reviewed at the end of May. In addition, further work is being done to understand the underlying cause of missed breaks on the basis that nurse leaders want to ensure that having a break whilst on shift is the norm and part of the culture we wish to promote. 8
Strategies to Address Shortfalls in Nursing & Midwifery ing Levels The Trust has a range of strategies which include recruitment, workforce redesign through the creation of new roles, retention and flexible staffing solutions. This section of the report provides an update on some of those strategies. Retention As outlined in a previous section of the report there is a focus on understanding the reasons for colleagues missing their essential rest breaks. On 12 May, International Nurses Day the Nursing and Midwifery leadership team reached out to all clinical areas across the ICFT to consult with colleagues and members of the public on the draft Nursing, Midwifery and Care Strategy. This was a very well received event with hundreds of colleagues participating and much positive feedback. The engagement opportunity 2 also provided a vehicle for saying thank you to our nurses, midwives and care colleagues for their contribution to care in Tameside and Glossop. An important part of any retention strategy is understanding how our colleagues perceive their services and would promote them to future colleagues. Throughout our preparations of the Nursing, Midwifery and Care Strategy all participants have been asked to use three words to describe our current nursing, midwifery and care offer to the population of Tameside and Glossop and the word bubble below captures those descriptions. Recruitment During the month of April 20 registered nurses left the organisation; a total of 17.42 wte and 22 registered nurses (19.6 wte) commenced employment with the Trust. On 12 May Just R were on site working with the Nursing and Midwifery leadership team to film a series of interviews and interventions leading to the production of a new recruitment video. The video will be used to promote the forthcoming recruitment events. The next open day for recruitment is scheduled for Saturday 10 June. It is understood that this date clashes with another recruitment event elsewhere in Greater Manchester however the interim Chief Nurse has made the decision to go ahead with a view to repeating our local event (if required) on 01 July 2017. 2 The second in 7 days with the first taking part on 05 May International Day of the Midwife. 9
In terms of international recruitment, the Nursing and Midwifery leadership team, with the support of colleagues in procurement, are meeting recruitment agencies on 24 May 2017. A verbal update may be available for the Board meeting on 25 May. Temporary ing The Trust works with NHS Professionals to provide a temporary staffing solution. In April 2017 the overall temporary staffing fill rate was 77.2%, a reduction on the overall fill rate of 78.7% in March 2017 despite a 15% reduction in demand. The top booking reasons remain vacancy, sickness, and 1-1 specialling. The graph below shows the fill rates and total requested hours for both registered and unregistered staff for the last 3 months. Working with NHSP several initiatives are being designed to attract existing nurses and care support workers to register with NHSP for bank shifts, the aim being to increase shift fill rates and reduce agency usage. The Nursing and Midwifery leadership team believes that tighter controls on agency usage are possible and therefore a practice deployed in most other Trusts working with NHSP will be implemented in Tameside and Glossop no later than June 2017; this will involve the use of Golden Keys which can only be removed to sanction the use of agencies, by a limited number of people. Trainee Nurse Associates (TNAs) The TNA Clinical Educator is now in place on a fixed term contract and will be supporting colleagues in the clinical placement areas. The TNAs are still on their first six month rotation and move to their second placement on 31 July. Practice based assessments will be taking place in June, reviewed by the Lead for Preceptorship and submitted to the Manchester Metropolitan University. The Board should note that TNAs only have two opportunities to pass the assessment and also need to submit a summative assessment before being able to progress to second placement. Appropriate support is being provided by both the corporate nursing team and the learning and development team. 10
Preceptorship In April 21 new registrants requiring preceptorship joined the ICFT: 15 x Adult Nurses (2 x Community and 13 x Acute) 1 x Paediatric Nurse 2 x Dieticians 1 x Learning Disability Nurse 1 x Community Physiotherapist 1 x ODP Summary The challenges associated with achieving safe staffing levels are well understood by the Board. Registered Nurse fill rates are low at 90.2%, supported by care support worker rates in excess of 100%. Three wards are consistently featuring in the list of those with fill rates <80% and this month specific action has been taken in relation to protecting Registered Nurse input to ward 42. Using the NHSI Model Hospital Dashboard it is apparent (based on January 2017 data) that the ICFT CHpPD is similar to 50% of other organisations. A review of School Nursing and Health Visiting is taking place within the respective Division; both services experiencing increased demand following the publication of the Ofsted Report in Tameside. Finally, the Board should note that an open recruitment day is scheduled to take place on 10 June with a further day planned (if required) for 01 July. In preparation for these events, new recruitment materials are being produced including a video that features services across the ICFT. Recommendations The Trust Board is asked to note the details of this report and the actions being taken. 11
Appendix 1 Inpatient Ward Compliments Complaints Moderate Harm + Incidents Falls with Harm MRSA C.Diff PU (+G2 only) FFT Positive (%) Registered Fill Rate - Days % of Temp Used Registered Fill Rate - Nights % of Temp Used Unregistered Fill Rate - Days % of Temp Used Unregistered Fill Rate - Nights % of Temp Used Planned Registered CHPPD Actual Registered CHPPD Planned Unregistered CHPPD Actual Unregistered CHPPD Planned Orthopaedic Unit 35 1 1 0 0 1 0 97.1% 90.5% 1.85% 93.1% 18.74% 116.6% 15.74% 154.4% 43.57% 3.45 3.8 2.93 4.3 8.0 Surgical Unit 69 2 0 0 0 0 0 100.0% 82.9% 9.05% 97.6% 14.65% 92.0% 35.34% 119.2% 53.66% 3.12 4.10 2.92 4.60 8.70 Emergency Orthopaedic Unit 24 0 0 0 0 0 0 97.4% 91.3% 2.02% 103.1% 23.93% 113.6% 17.81% 143.2% 41.17% 3.31 3.60 3.00 3.70 7.30 Critical Care 0 0 0 0 0 0 0 100.0% 95.3% 13.62% 94.4% 31.17% 91.5% 0.00% N/A N/A 25.0 34.60 1.33 1.80 36.4 AMU 5 2 3 1 0 0 2 91.8% 108.0% 9.61% 93.6% 38.11% 96.5% 11.70% 100.4% 14.16% 3.85 4.20 4.27 4.60 8.80 Acute Cardiology Unit 8 0 0 0 0 0 0 96.5% Heart Care Unit 6 2 0 0 0 0 0 100.0% Heat map - Inpatient Ward Areas - April 2017 83.7% 19.92% 107.5% 36.08% 122.0% 10.99% 96.8% 46.42% 4.65 4.20 2.91 3.00 7.20 Ward 31 4 1 0 0 0 0 0 88.4% 85.8% 46.30% 88.4% 77.31% 102.1% 37.69% 105.9% 64.44% 2.40 2.30 3.60 4.30 6.60 Ward 40 27 0 0 0 0 0 0 93.8% 80.6% 1.30% 95.6% 33.91% 75.0% 15.32% 150.3% 29.50% 2.40 2.30 2.79 3.10 5.30 Ward 41 63 0 2 1 0 0 1 82.4% 80.6% 11.67% 92.3% 48.43% 107.6% 16.09% 103.8% 37.77% 2.47 2.30 3.00 3.30 5.50 Ward 42 12 0 1 0 0 0 0 100.0% 68.8% 1.14% 92.9% 42.32% 117.8% 14.32% 124.4% 37.87% 2.80 2.40 3.14 3.40 5.80 Ward 44 24 0 1 0 0 1 1 97.1% 74.8% 15.38% 96.7% 41.58% 145.8% 21.04% 133.3% 38.85% 2.59 2.30 3.31 4.60 6.90 Ward 45 10 0 1 0 0 0 1 100.0% 84.0% 12.32% 95.0% 49.49% 109.6% 16.97% 100.0% 10.94% 2.50 2.40 4.25 4.50 6.90 Ward 46 11 1 1 0 0 0 0 100.0% 67.8% 4.87% 79.9% 31.53% 136.3% 11.31% 177.9% 31.19% 2.81 2.20 2.50 3.90 6.10 Ward 27 (Maternity) 22 1 0 0 0 0 0 88.7% 103.9% 15.30% 90.3% 9.01% 96.5% 12.81% 111.1% 22.25% 2.57 3.20 1.65 1.60 4.80 NICU 8 0 0 0 0 0 0 100.0% 99.2% 12.25% 99.2% 21.11% 100.0% 0.00% N/A N/A 7.38 10.80 0.66 0.80 11.70 Children's Unit 49 2 0 0 0 0 0 97.8% 99.1% 11.97% 94.5% 10.25% 69.9% 23.30% N/A N/A 3.93 8.70 0.99 2.30 11.00 Stamford Unit 1 0 0 1 1 0 0 0 103.0% 9.42% 98.4% 42.63% 98.6% 13.86% 101.7% 47.20% 1.50 2.00 3.75 4.50 6.50 95.2% Stamford Unit 2 0 0 0 0 0 0 0 100.1% 4.08% 101.7% 28.07% 96.1% 23.15% 103.3% 47.13% 1.50 2.00 3.75 4.30 6.30 Shire Hill 6 0 0 0 0 0 0 93.3% 100.3% 24.75% 100.1% 13.32% 93.0% 24.07% 97.6% 63.59% 2.33 3.10 3.33 3.90 6.90 Inpatient Totals/Averages 383 12 11 3 0 2 5 90.3% 90.2% N/A 95.6% N/A 103.5% N/A 116.6% N/A 3.5 3.7 3 3.7 7.4 Actual CHPPD TOTAL KEY Complaints Moderate Harm + Falls with Harm MRSA CDIFF PU(+G2) ing Fill Rates 0 - Green 0 - Green 0 - Green 0 - Green 0 - Green 0 - Green > 90% - Green >1- Amber >1 - Amber >1 - Amber >1 - Red >1- Amber >1 - Amber 80-90% - Amber >2 - Red >2 - Red > 2 - Red >2 - Red >2 - Red < 80% - Red NB: Please note that Inpt FFT Total shown does not include Community areas. 12