REPORT TO: STAFFORDSHIRE AND STOKEONTRENT PARTNERSHIP NHS
TRUST BOARD MEETING
TO BE HELD ON: WEDNESDAY 29THJUNE2016
Enclosure: / 05iSubject: / Safe Nurse Staffing: Community Hospitals Workforce and Patient Acuity Report – Cycle 7
Strategic Goal
(tick as appropriate): / X / We will provide high quality and safe services which provide an excellent experience and best possible outcomes
We will work with users and carers to deliver integrated services, simply and effectively
Our organisation will develop and deliver sustainable, innovative services that support independence
X / We will have the right people and time, well trained and motivated, able to deliver the right level of individual care
We will make excellent use of our resources and improve levels of efficiency across our services
Director Lead: / Rose Goodwin – Director of Nursing & Quality
Recommendation: / For Approval & Assurance / X / For Discussion / X / For Information
PURPOSE OF THE REPORT:
This report provides the Board with the findings and recommendations from the seventh acuity/nurse staffing establishment review which was carried out in January 2016.KEY POINTS:
- The National Quality Board and NHS England expect NHS providers to carry out a review of patient acuity versus nurse staffing levels on a twice yearly basis.
- The Partnership Trust has undertaken nurse staffing reviews consistently since 2012
- The seventh review cycle has identified a further increase in patient acuity necessitating an additional 33.67WTE staff at a cost of c. £815K.
- During 2015/16 the community hospital service spent approximately £1.9 million on temporary staffing (Bank and Agency) to support nursing vacancy and provide additional staff to meet increasing care needs.
- Challenges to recruitment to existing vacancies exist as a result of the national shortage of nurses although the organisation has a comprehensive recruitment plan which is seeing increasing numbers of staff joining the organisation.
INTER DEPENDENCIES:
Legal and/or Risk / NHS England requires all NHS organisations that provide inpatient services to review nurse staffing levels against patient acuity on a twice yearly basis. Failure to comply with this directive will invite greater scrutiny of the organisation and risk reputational damage.Failure to ensure safe nurse staffing levels may also result in litigation where patient/service user harm arises.
Clinical / The link between poor patient/service user outcomes and mortality rates has been intrinsically linked to safe nurse staffing levels.
Financial / To implement the proposed staffing changes will result in expenditure in the region of £815K.
HR / Recruitment to vacancies and management of sickness absence are priorities to ensure safe care delivery both of which require HR colleagues to work closely with operational and corporate managers in order to achieve success.
Social Care / This paper relates to nurse staffing levels in inpatient wards and there is no direct impact on Social Care
Staff and Trade Union involvement actions undertaken/planned / Support of staff and Trades Union representatives in ensuring sickness absence is managed effectively is required.
Patient & Public Involvement / This paper will be presented in the Public Board meeting
Equality Impact / There is no equality impact issues associated with this report.
Information exempt from Disclosure / None
Requirement for further review / Safe staffing levels are reviewed at Board on a monthly basis and a detailed review of establishment profiles against patient acuity will take place on a twice yearly basis.
RECOMMENDATIONS:
The Board is requested to:- Receive the report and acknowledge its content
- Be assured that the gaps in nurse staffing is being managed effectively
- Recognise the risks associated with the use of temporary staffing and subsequent costs
- Support the proposed shift changes for each ward
Safe Staffing: Community Hospitals Workforce and Patient Acuity Report – Cycle 7
Background
Following the publication of the Francis Report, the National Quality Board (NQB), in conjunction withthe Chief Nursing Officer (CNO),set out the expectations for all commissioners and providers for safe nursing and midwifery staffing. NICE were tasked by NHS England to produce guidance to ensure that nurse staffing levels are fit for purpose and at the appropriate level. Guidance was produced for inpatient wards in acute hospitals (July 2014) and midwifery and maternity settings (February 2015). However in June 2015, NICE was asked to suspend further work on the safe staffing programme as the work would be taken forward by NHS Improvement, in conjunction with NHS England. This work would form part of the wider programme of service improvement; exploring alternative approaches to support NHS providers achieve the right levels and mix of healthcare staff, rather than just focusing on the nursing and midwifery provision.
In June 2014 Lord Carter of Coles was asked by the Secretary of State for Health to look at what could be done to improve efficiencies in acute hospitals in England. In February 2016 his report, Operational productivity and performance in English acute hospitals: unwarranted variations, was published. The report suggests that the variation in people management across the NHS is having a negative impact on productivity improvement. The team working with Lord Carter engaged with Directors of Nursing to look at how nursing staff could be best used. There was a wide variation in practice across acute NHS Trusts in how to reduce absences, improve productivity and manage the need for temporary staff. The report recommends a new approach to calculating staffing levels using Care Hours Per Patient Day (CHPPD) as the basis for ensuring safe staffing levels. NHS Employers will be working with the National Quality Board (NQB) to assess the merits and applicability of this new model.
Demonstrating sufficient staffing is one of the essential standards that all healthcare providers must meet in order to be compliant with CQC requirements. Staffordshire and Stoke on Trent Partnership NHS Trust (the Partnership Trust) has reviewed inpatient nurse staffing since July 2012 and the Director of Nursing and Quality has provided the Trust Board with assurance of compliance with national requirements on a regular basis since that time, both in relation to monthly assurance reports and twice yearly review of staffing against patient acuity.
NHS organisations are required to carry out twice yearly reviews of nurse staffing based on patient acuity and dependency needs. The Partnership Trust is committed to ensuring that there is the appropriate level and skill mix of nursing staff, having undertaken reviews of nurse staffing establishments for the past 3 years and has consistently invested to ensure appropriate staffing and skill mix on the inpatient wards it operates..
The purpose of this paper is to present the six month review of the acuity and dependency of in-patients against nursing staff establishments and skill mix building on the previous patient acuity reviews and does not include data relating to Allied Health Professionals or Medical staff.
Staffing Levels and Ratios
A ratio of one registered nurse to a maximum of eight patients is seen nationally, as the threshold for provision of safe care during daytime shifts. It is widely acknowledged that this ratio or better does not guarantee safe care but evidence from the RCN, NQB and NICE all suggest that when that ratio is exceeded additional pressures are experienced by the nursing staff and care standards as well as patient outcomes may deteriorate.
The National Quality Board in 2012 set out an expectation that there will be a minimum of two registered nurses on duty on each shift, regardless of ward size or patient need. Failure to meet this expectation was considered a ‘red flag’ and in acute hospital trusts, reportable as part of the safe nurse staffing metrics.
When setting safe staffing levels it is important that the focus is not just on achieving a minimum registered nurse to patient ratio (1:8)but other factors such as ward layout/ general environment, patient presentation and specific care needs must also be considered alongside professional judgement. The Partnership Trust recognises the challenges associated with, particularly, the layout and patient specific care needs and operates a patient to nurse ratio based on both professional judgement and acuity review findings.
At night the one to eight ratio is not always appropriate to care needs, particularly where patient activity at this time is low and the majority of NHS Trusts operate a ratio of one registered nurse to ten patients. The bed capacity for each ward operated by the Partnership Trust varies from ward to ward (between ten and thirty two beds) and in order to provide at least two registered nurses on duty the ratio (at night) varies between one registered nurse to five patients and one registered nurse to thirteen patients.
Ensuring that there is adequate leadership and supervision at ward level from the Ward Sister or Charge Nurse is a key message from both the Francis and Keogh reports. Provision of a positive role model who is visible to patients/service users, their families and staff is fundamental to ensuring a well-run ward. The Ward Managers working in community hospitalservices are allocated 0.5WTE of their working week to act in a supervisory capacity.
Safer Nursing Care Tool
The Safer Nursing Care Tool, developed by the Shelford Group (formally the Association of UK University Hospitals – AUKUH) has been used in all staffing reviews undertaken in the Partnership Trust.
It is an evidence based toolthat enables teams to assess patient acuity and dependency, whilst, incorporating a staffing multiplier to ensure nursingestablishments reflect patient needs. The tool has been endorsed by NICE, in line with the guidance for Acute Hospital Inpatient wards (2014) and includes twenty two percent uplift for planned leave (study and annual leave).
Validated by Dr Keith Hurst (formally of Leeds University), the validation process included recalibrating the tool using the UK Nursing Database, which at that time included 1,000 best practice wards (those achieving a pre-determined quality rating) and some 119,000 nursing interventions delivered to almost 2,800 patients in 14 care groups over two years.
The tool is applied to all patients present on the ward over a period of time; locally a minimum of four weeks is felt to provide an adequate spread of clinical activity. Patients are characterisedagainst four acuity/dependency levels (table 1) and the multiplier for each level applied to determine the suggested establishment. This figure is moderated by professional judgement which takes into account the clinical environment, throughput and any external factors which may apply.
The Community Hospital services include step up and step across models of care, supporting assessment of future care needs, rehabilitation and support for individuals at the end of life and does not provide care at levels 3 and 4 as set out in table below.
Table 1: Safer Nursing Care Tool - Levels of Care
LEVEL / MULTIPLIER / DESCRIPTOR0 / 0.99 / Patient requires hospitalisation and routine nursing care & intervention
1a / 1.39 / Acutely ill patient requiring intervention or those who are unstable with a greater potential to deteriorate
1b / 1.72 / Patients who are in a stable condition but have increased dependence on nursing support to meet most or all of the activities of living
2 / 1.97 / Patients who are unstable and at risk of deteriorating and should not be cared for in areas currently resourced as general wards
May be managed within clearly identified, designated beds, resources with the required expertise and staffing level OR may require transfer to a dedicated Level 2 facility / unit
3 / 5.96 / Patients needing advanced respiratory support and therapeutic support of multiple organs
Safe Nurse Staffing Review Cycle 7
The review took place during January 2016 (31 days). The Safer Nursing Care Tool, developed by the Shelford Group and validated by NICE, was used to review patient acuity and staffing levels. The overall ward establishments are developed based on this information and that gained from professional judgment. Appropriate shift patterns and skill mix are identified following discussion with ward sisters and hospital matrons.
The reviews are undertaken twice yearly; once in summer months and again during the winter time so as to take into account seasonal variation.
Table 2: Funded Establishment versus Acuity Establishment
Ward / Beds / Funded Establishment(WTE) / Cycle 7 Acuity
Establishment (WTE)
Scotia / 10 / 18.01 / 12.47
Grange / 32 / 41.76 / 47.37
Jackfield / 20 / 29.38 / 33.23
Broadfield / 23 / 38.66 / 35.91
Sneyd / 20 / 31.24 / 33.87
Chatterley / 25 / 32.65 / 38.61
Cottage / 19 / 26.96 / 24.23
Saddler / 17 / 25.96 / 30.80
Table 2 outlines the findings of the establishment review against patient/service user acuity (including 0.5 WTE supervisory time for Ward Sisters). Funded establishment was provided by HR and Finance colleagues through the Electronic Staff Record (ESR) and ledger for each ward.
Table 3: Ward Establishment and Skill Mix Profile
WARD ESTABLISHMENT & SKILL MIX PROFILEWard / Beds / Funded
Establishment
(ESR/Finance) / Acuity
(Cycle 7) / Current Shift Pattern / Proposed Shift Pattern
E / L / N / E / L / N
Scotia / 10 / 18.01 / 12.47 / 4(2/2) / 3(2/1) / 2(2/0) / 4(2/2) / 3(2/1) / 2(2/0)
Grange / 32 / 41.76 / 47.37 / 10(5/5) / 7(4/3) / 5(3/2) / 13(5/8) / 11(5/6) / 7(3/4)
Jackfield / 20 / 29.38 / 33.23 / 7(3/4) / 6(3/3) / 3(2/1) / 8(3/5) / 7(3/4) / 3(2/1)
Broadfield / 23 / 38.66 / 35.91 / 10(4/6) / 6(3/3) / 3(2/1) / 9(3/6) / 6(3/3) / 4(2/2)
Sneyd / 20 / 31.24 / 33.87 / 7(4/3) / 7(3/4) / 3(2/1) / 8(4/4) / 6(3/3) / 4(2/2)
Chatterley / 25 / 18.01 / 38.61 / 8(4/4) / 7(4/3) / 4(2/2) / 10(4/6) / 8(3/5) / 5(2/3)
Cottage / 19 / 26.96 / 24.23 / 6(3/3) / 5(3/2) / 3(2/1) / 7(3/4) / 6(3/3) / 3(2/1)
Saddler / 17 / 25.96 / 30.80 / 6(3/3) / 5(3/2) / 3(2/1) / 6(3/3) / 5(3/2) / 3(2/1)
Proposed changes to shift
Table 4: Proposed Establishment, Skill Mix Profile and RN to Patient Ratio
Ward / Beds / Funded Establishment / Acuity Establishment / Proposed Shift BasedEstablishment / Shift Pattern / RN to Patient Ratio*
Early / Late / Night / Early / Late / Night
Scotia / 10 / 18.01 / 12.47 / 17.01 / 4(2/2) / 3(2/1) / 2(2/0) / 1:5 / 1:5 / 1:5
Grange / 32 / 41.76 / 47.37 / 57.43 / 13(5/8) / 11(5/6) / 7(3/4) / 1:7 / 1:7 / 1:11
Jackfield / 20 / 29.38 / 33.23 / 32.95 / 8(3/5) / 7(3/4) / 3(2/1) / 1:7 / 1:7 / 1:10
Broadfield / 23 / 38.66 / 35.91 / 35.23 / 9(3/6) / 6(3/3) / 4(2/2) / 1:8 / 1:8 / 1:12
Sneyd / 20 / 31.24 / 33.87 / 31.81 / 8(4/4) / 6(3/3) / 4(2/2) / 1:5 / 1:7 / 1:10
Chatterley / 25 / 32.65 / 38.61 / 42.63 / 10(4/6) / 8(3/5) / 5(2/3) / 1:7 / 1:9 / 1:13
Cottage / 19 / 26.96 / 24.23 / 29.54 / 7(3/4) / 6(3/3) / 3(2/1) / 1:7 / 1:7 / 1:10
Saddler / 17 / 25.96 / 30.80 / 26.12 / 6(3/3) / 5(3/2) / 3(2/1) / 1:6 / 1:6 / 1:9
* Rounded up to whole number
Staffing Requirement
There has been an increase in patient acuity across the majority of ward areas since the sixth cycle of acuity review was undertaken in the summer of 2015. The clinical leads within the service have provided a proposed safe staffing profile for each ward, based on professional judgement and temporary staff usage (as reported through the monthly safe staffing dashboard) over the six month period. Where necessary, the wards have amended their shift profile to accommodate the need for close observation and support to those at risk of harm (table 4), resulting in an increase in care worker establishment of 33.67WTE at a cost of £813,329; this figure includes twenty two percent uplift and application across the full seven days.
Safe nurse staffing levels are reviewed on a shift by shift basis at ward level and weekly by the Professional Head of Nursing who provides challenge and scrutiny to the rostering process. The Partnership Trust Board receives an assurance report on this matter monthly and it is appraised of challenges to safe staffing at this time. As reported each month, the community hospital service has maintained safety by staffing to meet patient’s needs. There has been an increasing requirement for additional staff to support individuals with complex physical and cognitive health needs, who are at risk of falls, resulting in between fifty and sixty percent of all shifts having additional care workers rostered above the agreed establishment. In the current Safe Nurse Staffing Levels report to Trust Board, sixty three percent of shifts had one or more care workers rostered on duty to meet additional care needs. Additional staffing, to maintain safety, comes at an additional financial cost and during 2015/16the community hospital service spent £1,853,017on temporary staff to support close observation and fill gaps in rotas as a result of vacancy and absence.
Challenges to Service Delivery
The last acuity review took place in the summer of 2015 and since that time the service provision within inpatient services has changed significantly; on 01 April 2016 the inpatient services at two hospital sites, Bradwell and Cheadle hospitals, transferred to the University Hospital of North Midlands (UHNM) and the remaining inpatient services (non-speciality) moved towards a step up model. Over time the acuity and dependency of those using inpatient services has increased, as demonstrated by each acuity review since 2012. The data provided in these reviews are validated by both hospital matrons and the professional leadership team.
A number of the wards experience specific challenges with regard to providing safe nursing levels and skill mix, although patient safety is ensured. An ongoing challenge is that of ward lay-out and design, which impacts on the ability to supervise and monitor individuals, particularly those with cognitive impairment and at risk of falls, resulting in the need for additional temporary staff.
Scotia Ward
Scotia Ward, a ten bedded specialist rheumatology ward, faces a particular dilemma. There is a national requirement for at least two registered nurses to be on duty on each shift, resulting in a registered nurse to patient ratio of 1:5 (full occupancy) on this ward; with this figureincreasing as bed occupancy declines/fluctuates. In addition, many of the treatments provided require use of pharmacological agents which are complex to prepare and administer, often requiring supporting clinical education and additional monitoring by registered nursing staff. Consequently it is difficult to effectively utilise nursing staff, whilst providing the appropriate treatment and interventions as well as complying with national guidance.
Grange Ward
The new model of care delivery has seen a move towards a ‘step up’ approach, focusing on avoiding unnecessary acute hospital admission. In order to facilitate effective and smooth flow in to the service, Grange Ward at Haywood Hospital acts as the main port of entry into hospital services. Although designated as a step up ward, this thirty-two bedded area operates in the same manner as a Frail Elderly Assessment Unit (FEAU), where patients are admitted for assessment, stabilisation of their health problems and an initial treatment and care plan implemented before transfer to another ward in the service for ongoing care and rehabilitation.