SUMMARY REPORT Trust Board 29 November 2013

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1 SUMMARY REPORT Trust Board 29 November 2013 Subject Prepared by Approved by Presented by Nursing Establishment Report Workforce Development Manager and Deputy Director of Nursing Purpose The purpose of this report is to provide clarity and assurance around the current nursing establishment, vacancies and recruitment activity, whilst also highlighting the historical processes for setting nursing establishments across the Trust. Corporate Objectives Quality Care Inspired People Healthy Organisation Executive Summary Decision Approval Information Assurance Innovate & Collaborate The report shows that the gap between agreed establishment and staffing levels has been consistently reducing since the start of the year with recruitment activity matching the current vacancy position. Quality Impact Assessment As this report is principally around the methodology and process of setting safe staffing levels, it impacts on all aspects of patient care as well as the inherent financial implications of budget setting. Financial Impact Assessment Impact on budget setting across nursing areas. Regulatory Impact Assessment CQC outcomes 12, 13 and 14. Equality and Diversity Impact Assessment Maintaining the correct staffing levels will support the implementation of the Trust s EDS objectives. Recruitment of staff must be managed to avoid any form of unlawful discrimination. Key Recommendations The Trust Board is asked to consider the assurances provided and to identify any additional actions it requires to obtain improved assurance of safe ward staffing levels. Next Steps Continue to recruit to agreed, revised, establishment levels; implement the NHSP e-rostering interface, and continue to provide a suite of monthly nurse staffing reports to all nursing managers and the Executive Team. 1

2 DETAILED REPORT Trust Board 29 November 2013 Subject Prepared by Approved by Presented by Nursing Establishment Report Workforce Development Manager and Deputy Director of Nursing 1. Purpose The purpose of this report is to provide clarity and assurance around the current nursing establishment, vacancies and recruitment activity, whilst also highlighting the historical processes for setting nursing establishments across the Trust. The public concern around Nursing and provision of care has been all too frequently highlighted in the media in the last year or more. The Francis report, Keogh report and Berwick report all emphasised the importance of robust and consistent Nurse and Healthcare Assistant staffing levels, in providing safe and effective personalised care. In addition, as set out in the implementation plan for the 6C s, they emphasised the Board s responsibility in ensuring they understood and regularly reviewed Nurse staffing in their organisation. The paper examines the following: the current staffing profile within nursing and the reporting that provides assurance around staffing gaps; actions taken to review the nursing establishment over the past twelve months; the methodology that is in place to inform decision making in terms of recruitment and establishments and who is involved in that decision making; and how we benchmark and intend to monitor appropriate staffing levels in relation to beds occupied, to provide ongoing assurance that we have safe nursing levels. 2. Current nursing profile and reporting process The nursing staffing reports are updated monthly and are available electronically via the nursing quality data drive. This provides comprehensive assurance around nursing numbers, skill mix, bed state, discretionary pay usage, sickness and maternity leave, and current vacancies against current recruitment activity. The report enables the reader to drill down to individual cost centre level. In addition to the current staff in post and establishment, the reports also detail the revised establishments that are updated by the Head Nurses and Finance, in order to give an establishment vacancy position and also a recruit to level. Figure 1 shows the latest (1 October 2013) and historic KPI figures for ward and other frontline areas and includes the current and historic vacancy levels as held in the Finance general ledger. 2

3 Figure 1 Over the past six months, vacancy levels have fluctuated due to increased recruitment activity matched against increased establishment levels with a sizable drop in September. The trend for absence, both sickness and maternity, is encouraging with both showing net reduction over the same period. NHSP and agency usage has fluctuated over the period with a steady rise until August which has dropped in September. Draft establishment figures for October show a 20 FTE increase in nursing staff in post against an increase in establishment of 34 FTE resulting in a circa 14 FTE increase in vacancies. Annex 1 shows a summary of the KPIs for ward and frontline clinical areas, as well as including other nursing to give a complete picture. In the interests of conciseness, this uses a summarised version of the nursing staffing reports (the full reports include skill mix and have over 180 rows detailing the precise breakdown for individual department managers). This report also gives the recruit to establishment as opposed to the ledger position, to enable recruitment and services to know exactly what the recruitment target is. Whilst the ledger vacancies as shown in Figure 1, for ward and other frontline clinical services, total just over 125 FTE (1 October 2013), the recruit to establishments shown in Annex 1 demonstrates that there are actually 189 FTE vacancies that have been agreed and need to be recruited to. This is balanced against recruitment activity of 205 FTE and is currently being backfilled by 163 FTE bank and agency nurses/hcas. Due to the recent fall in the number of establishment vacancies as well as a reduction in sickness absence, the monthly nursing discretionary pay figure has fallen from 553k in May to 478k in October. This trend looks set to continue with the start of November seeing an additional 10% drop in demand for nursing and HCA shifts. 3

4 Whilst these reports focus on frontline clinical areas, the full nursing reports contain data for all nurses/hcas and ODPs across the Trust and this is available to all nursing managers. The Nursing and Midwifery Operational Committee will triangulate this data with the monthly reports in respect of nursing sensitive quality indicators (i.e. pressure ulcers, falls) as well as complaints, Family and Friends test and our own inpatient and staff surveys. In addition to the above reports, Finance and the Directorate of Nursing have initiated a series of reports that show the current live position on the wards and the precise staff in post against newly agreed establishment. This information is reviewed at the weekly Heads of Nursing meeting chaired by the Director of Nursing, and provides additional assurance that posts being recruited to have been fully agreed and that posts are not left dormant. 3. Historical establishment reviews The nursing establishments are reviewed annually with in year changes occurring to match activity and operational plans. These have been agreed with the Deputy Director of Nursing and worked up via the Heads of Nursing and Matrons. The past year has seen a fundamental review; this commenced in September of 2012 and was extended to take account of the Francis Report. This review culminated in a report to the May 2013 Trust Board with significant investment in our Nursing establishments being agreed. This review had three key tenets: 1. Ensuring that, unless there was a clear clinical reason to the contrary, our establishments had an RN to HCA ratio of not less than 60: Establishing the principle of a ratio of 1 RN: 8 patients as a minimum standard; this included establishing a higher ratio of RN s where required. 3. Establishing the principle of Supervisory ward managers for 37.5 hrs (i.e. full time) as opposed to the 22.5hrs previously provided. This review agreed establishments that will improve the quality, safety and patient experience for the future, recognising the increased acuity and dependency of our patients. This will also provide greater operational stability and reduce the reliance on temporary staffing across the wards in the Trust. The challenge will be to continue our recent recruitment success into the future and thus deliver a sustained improvement to Nursing care as measured by Nurse sensitive quality indicators. The agreed 2013 review has recently been the subject of an interim review, in light of the Trust s financial position, to ensure that ward establishments remain both safe and financially sustainable for the remainder of this financial year. Future increases in establishments have been risk assessed by the senior Nursing team and Finance and thus some interim control measures have been applied: 1. Delayed introduction of the full-time supervisory status for Ward Managers/Charge Nurses. This will now be introduced in April Recognition of the fact that some planned increases in shift numbers cannot be achieved until recruitment enables it; meaning some uplifts will now be deferred until April Methodology for setting nursing establishments Whilst a small number of nursing areas have patient and skill mix ratios pre-determined (e.g. ICU/HDU), for other departments, safe staffing levels are decided for each ward in agreement with the Director of Nursing via the Deputy Director of Nursing and the senior nursing team. 4

5 Determining and proposing establishments has been based on the use of three methods to ensure triangulation and constructive challenge to both ward teams and those agreeing the Nursing resource. These methods are: 1. Use of the AUKUH Safer Nursing Care tool. This involves a month long assessment of acuity and dependency conducted at ward level, with data then being uploaded into a tool that calculates total establishment required. 2. Application of the Professional judgement model. This is supported by a calculation tool designed by the Deputy Director of Nursing and a senior member of the Finance team. It involves reference to the AUKUH model and a shift by shift review of required skill mix, to deliver care from the professional opinion of the Ward Manager/Charge Nurse (i.e. experience based). This is undertaken with the relevant matron, ward manager and service line manager. 3. Reference to any national recommendations from the Department of Health and professional bodies such as the Royal Colleges. Additionally, the Audit Commission Ward Staffing benchmarking audit has been used as a reference point. (It is worthy of note that renewed guidance is anticipated on the 18 th of November; this will be built into a revised process for 2014). The process described above applies in the main to Wards within the Trust. The following applies for other areas: 1. Maternity establishments are reviewed using the Birthrate+ tool (BR+). This is a nationally recognised tool and was applied recently as part of the 2013 review and uplifts subsequently agreed. External benchmarking is a standard part of the BR+ analysis. 2. Paediatrics to date have used RCN guidelines, with no set frequency of reviews. This was addressed in the 2013 review with an uplift agreed to attend to a gap as a result of a previous review that reduced posts. Currently the Paediatric team have been trialling the PANDA tool (Great Ormond Street tool). 3. Outpatient and non-ward clinical departments (such as Imaging) are reviewed normally as part of service reconfigurations and to date have not been subject to regular review. 4. Theatres are reviewed on the basis of sessional activity by individual directorates. Following the change to Theatre Central a full review has been commissioned and is currently being completed. Part of a proposed establishment for Nursing includes an uplift to cover annual leave, study leave, sickness and maternity. Current Royal College of Nursing (RCN) guidelines recommend a 25% uplift; the 2013 Trust review increased our uplift from 21.5% to 22.5% (having originally proposed 23.5%). Once staffing levels have been agreed by the senior nursing team, this is then agreed with the Care Groups and Finance, in order to be incorporated into individual cost centres. At this point, recruitment, training and the wider HR and corporate functions support the department, in ensuring that those levels are maintained, new posts are recruited to and members of staff receive the correct levels of training and competencies necessary to fulfil their roles. 5

6 It is then the responsibility of each individual ward manager and Matron to ensure that minimum staffing levels are maintained at all times via efficient rostering, to ensure safe and effective levels of care are provided to all patients. 5. Assurance around safe staffing levels On a day to day basis, nursing staffing levels are discussed at the operational team meetings led by the Matrons, the operational site management team, the on-call manager, and where necessary the on-call Executive Director. This ensures that wards and departments are appropriately staffed in order to meet the changeable demands on the hospital. Should projected minimum staffing levels not be achieved, flexible working across the departments is overseen on a day to day basis by the duty senior nurse and the Acute Care Team. Discretionary pay is utilised on a planned basis to cover known shortfalls and following risk assessment of the daily position, on a short-term basis to cover unplanned absence. This includes, where necessary, the use of Agency Nursing staff via an approval process at Director/Deputy Director/Head of Nursing level. E-rostering is in place across all ward areas to ensure that any unfilled shifts are visible in advance, enabling managers to flex their workforce efficiently and with the minimum disruption to the continuity of patient care. Significantly and very importantly, the planned link between NHS Professionals and e- rostering will be going live in the first couple of months of All booking of temporary staffing will then take place through the e-rostering system. This will enable a complete live and integrated picture of nursing staffing levels at both a micro and macro level. This, alongside the ability to automatically roster departments, will make the rostering of staff less time consuming and will ensure that shifts can be covered in advance and exceptions will be highlighted at an early stage. It will also give the senior nursing team a complete, real-time view on nursing staffing levels without relying on two separate, non-integrated systems. In the longer term, the nursing staffing reports highlighted above not only give assurance around staff in post but give a view around how the establishments are working operationally. For example, whether or not the discretionary pay usage is indicating the need for an establishment review, in a particular department. 6. Conclusion and recommendations The processes for establishing safe staffing levels in clinical nursing areas described above, have been led by the senior nursing team in partnership with Finance and HR. Assurance in relation to staffing levels is provided on a short, medium and long term basis, and is supported by robust reporting. In the light of progress on the e-rostering project, further developments for reporting will be agreed with the senior nursing team. It is therefore recommended that: 1. We continue with the current agreed methodology for establishment setting going forward, to be incorporated into the workforce plans for each department and Care Group. 2. We further enhance this by revising our process so that it includes reference to nursing sensitive indicators of care in each review. 3. The Trust continues to recruit to vacancies up to agreed, revised establishment levels, ensuring that departments have sufficient substantive staff in post and discretionary pay is only utilised in exceptional circumstances. 4. The Trust Board receives a report on Nurse staffing levels every six months. 6

7 Annex 1 Summary of the KPIs for ward and frontline clinical areas Area Beds To recruit to FTE Current Staffing FTE Recruitment Vacancies being recruited to Core Esc'n Open Total RN HCA Total RN HCA Total RN HCA Total Adv ert Checks Start date Maternity Leave Absence Short Term Absence Long Term Absence Total RN HCA Total Total Total Total Wards Other Frontline Clin Areas Total Vacancies FTE NHSP/Agency Shifts FTE 7

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