The Newcastle upon Tyne Hospitals NHS Foundation Trust. Nursing and Midwifery Staffing Strategy

Transcription

1 The Newcastle upon Tyne Hospitals NHS Foundation Trust Nursing and Midwifery Staffing Strategy Incorporating Guidelines to Ensure Safe Nursing and Midwifery Staffing Levels within the Newcastle Upon Tyne Hospitals NHS Foundation Trust Version No.: 1.0 Effective From: 29 October 2014 Expiry Date: 29 October 2015 Date Ratified: 1 October 2014 Ratified By: Senior Nursing Team 1 Introduction The purpose of this document is to: Set out the principles that underpin safe Nursing and Midwifery staffing for the wards, departments, clinics and community services provided by the Trust. Describe the methodology undertaken to agree funded Nursing and Midwifery establishments and skill mix. Demonstrate how these are monitored to ensure that they remain fit for purpose specifically to ensure appropriate staffing levels are provided to meet the dependency and acuity of patients in our care. Detail the process for regular and responsive review. Define the levels of responsibility by role regarding staffing levels. Identify the escalation process and steps to be followed to meet the demands of short term and long term staffing problems. Confirm the risk monitoring & management arrangements. 2 Scope of Strategy This strategy refers to the professionally istered & unqualified Nursing & Midwifery workforce. 3 Aims The purpose of this document is to provide assurance to Trust Board, Governors, staff and patients, that Nursing and Midwifery baseline staffing levels and skill mix are set at appropriate levels to ensure high quality care is provided to patients, and that a clearly defined process is in place to assist senior Nurses and Midwives to address staffing challenges. It also provides for the review and refinement of future staffing levels and skill mix requirements to meet the changing care needs of the Trust s patient population. It should be read and considered in conjunction with the Trust Electronic Rostering & Attendance Policy (ERA). Page 1 of 14

2 The Trust last performed a nurse staffing review in 2005 /2006 and since that point many changes have been made as a result of service developments and reconfiguration. The 2013/14 NSR sought to provide clarity across the Trust regarding Nurse staffing levels and Nursing establishments within in patient Wards. However, there is a requirement to ensure that areas excluded from this review also have processes in place to routinely review their staffing requirements and to ensure that they are in a position to be responsive to changing patient care needs. Relevant national guidance has been incorporated. 4 Duties & Responsibilities 4.1 Trust Board Ensuring that all Wards, Departments & community based facilities have Nursing & Midwifery staffing levels and funded establishments which have been professionally agreed and are fit for purpose, to support those with responsibility for staffing decisions on a shift by shift basis. The Nursing & Patient Services Director is responsible for reporting monthly staffing levels to Board. This includes comparisons between planned and actual staffing levels reasons for any gaps and actions to address these. Any issues as well as trends in the context of key quality and outcome measures are included. The Nursing & Patient Services Director is responsible for agreeing any changes to Nursing & Midwifery establishments. Changes must have the approval of the Trust Board. 4.2 Heads of Nursing / Midwifery / Patient Services Heads of Nursing/Midwifery/Patient Services on behalf of the Nursing & Patient Services Director have professional responsibility to guide and support Directorate Management Teams in respect of staffing levels and skill mix and support Matron and Directorate Mangers to resolve any significant problems, and to escalate unresolved concerns. They are required to ensure monitoring of staff on a shift by shift basis is in place, managing immediate adverse implications and identifying trends in a planned and responsive way. 4.3 Directorate Managers Directorate Mangers are managerially responsible for all staff in their Directorate. They are responsible to find staffing solutions and escalate contingency plans within their Wards/departments. They are required to work collaboratively with the Matron to ensure the Matrons are effectively managed and well supported regarding Nursing and Midwifery staffing. 4.4 Matrons Matrons as part of Directorate Management Teams are responsible for agreeing establishment levels and ensuring Ward and department staffing is well managed. They are also responsible for ensuring effective and safe Page 2 of 14

3 management of the Nursing resource across their area of responsibility on a shift by shift basis, including escalation & contingency plans including out of hours cover arrangements. They are required to ensure that details of who is in charge of the shift, planned and actual staff information is accurately displayed on each Ward / department. That regular monitoring of planned and actual staffing on a shift by shift basis is in place and that this is reviewed in a planned and responsive way. 4.5 Ward Sister / Charge Nurse The Ward Sister/Charge Nurse has 24 hour accountability for a defined area. They are responsible for recruitment & retention of staff and planning rotas, as well as dealing with any changes or shortfalls in staffing, and for escalating concerns when these are unresolved. They are responsible to ensure the number and skill meets of staff meets the needs of the patients. They need to ensure that details of who is in charge of the shift, planned and actual staff information is accurately displayed on each Ward / department The Ward Sister/Charge Nurse should be a visible and credible leader to staff and patients. All Sisters/Charge Nurses will have identified supervisory time. 4.6 Patient Services Coordinators Patient Services Coordinators, as site managers, in the out of hours periods have the authority to deploy nurse staffing resources. They are also responsible to alert the Senior Manager on call if significant issues of concern arise with staffing. 4.7 istered Nurses / Midwives Being aware of this strategy and its content. Taking action to address and report any difficulties with staffing. Collaborating with colleagues, to address staffing shortages and surplus and being responsive in this. 5 Methodology and Framework for Staffing Currently there exists no single process or method to understand/define nurse staffing levels, and the relationship between care processes, Nursing care quality, patient and staff experience. There are some nationally mandated staffing levels for areas such as Paediatrics and Critical Care, and professional bodies such as the RCN/M have made recommendations for staffing levels which can be found in the reference list below. Where absolute requirements exist for example Critical Care, the Trust supports a position of compliance. In respect of guidance, for example RCN standards, then these are regularly reviewed and considered in decision making processes Changes or deficiencies in the Nursing & Midwifery workforce can have a profound effect upon the fundamental safety of patients and also on their care and experience. This has been demonstrated by recent enquiries into failings, not least of which was Page 3 of 14

4 the Francis Inquiry into the failing in Mid Staffordshire Hospitals (Feb 2013) Consistent throughout these cases was a failure to link the impact of changes in the workforce to patient care, combined with a lack of professional scrutiny and Board level consideration of changes. Acuity and dependency tools such as the Safer Nursing Care Tool (SNCT) are increasingly used by Trusts to assist in setting appropriate nursing establishments however these generally include a degree of subjectivity and in the Trust will be used as an adjunct to clinical and professional judgment. 5.1 Principles for assuring that nursing and midwifery establishments and staffing levels are fit for purpose and ensure patient safety There are four main ways in which assurance is provided that funded staffing establishments at Ward and department level are correct. (i) (ii) (iii) (iv) The Trust has a strong framework and culture of professional Nursing & Midwifery leadership. Explicit within senior Nursing roles, Ward Sister/Charge Nurse, Matron, Head of Nursing, is the responsibility for safe and effective Nurse staffing levels. Site cover is provided out of hours 24/7 by a team of senior Nurses (Patient Service Co-ordinators) with access to an on call manager. Every ward and department has a funded establishment which has been agreed based upon a robust methodology (further defined below). Any nationally mandated levels are followed (e.g. Critical Care areas, Midwifery). Formal regular review of this is in place. Monitoring of actual against planned staffing levels should happen on a shift by shift basis; these are reported monthly via NHS Choices and the Trust webpage. Monthly assessments of patient acuity / dependency is undertaken on in patient areas using SNCT, and reported monthly via the Trust s Clinical Assurance Tool; this forms part of a monthly Trust Board paper which is made public via the Trust webpage. Benchmarking of staffing establishment both internally and externally with comparable organisations. 5.2 Decisions About Staffing- Principles & Process Principles Whilst principles have been established these remain as a guide only. 1. Adult inpatient Wards: Band 7 Senior Sister/Charge Nurse and a minimum of 1.0 wte band 6 Sister/Charge Nurse as support. Housekeeper & Ward Clark roles. All wards and departments have an agreed skill mix and staffing numbers. 2. Paediatric Wards: 1.00 Band 7 Senior Sister/Charge Nurse and a norm of 2.0 wte band Page 4 of 14

5 6 Sister/Charge Nurse as support Play Specialist and Nursery Nurse support Staffing Ratios (as per RCN Guidance) Under 2yr olds 1:3 Above 2yr day 1:4 Above 2yr nights 1:5 3. Maternity Women in established labour 1:1 Midwife care In patient wards as in section 1. There is a BR+ recommendation to work towards 29:1 births to 1WTE midwife Ratio (BR+) 95 cases to 1WTE midwife (Community) 4. Each Ward or department will identify a nurse in charge on the off duty for each shift. They will then be identified by name on the Our staffing today sheet on the Patient knowing how we are doing board. 5. Critical Care units are compliant in funded establishments with national guidance - all have dedicated Matron roles with 0.5 wte clinical practice incorporated, Clinical Educator roles, Outreach support, and Band 7 Sister/Charge Nurse cover 24/7. 6. Band 7 Sister/Charge Nurse cover is augmented in specialist areas (e.g. ED, AS, Critical Care) to 24/7. In these areas the band 6 and 7 Sister/Charge Nurses may work less than 37.5 hours as agreed by Matron/Directorate Manager and Head of Nursing. 7. Each Band 7 or Senior Ward Sister will routinely work Monday to Friday to provide leadership commensurate with the role. In agreement with the relevant Matron, changing this pattern of work can be negotiated in some circumstances/on some occasions. This may be when there is a need for them to gain experience at other times such as weekends or nights. Band 7 Sisters/Charge Nurses will generally be expected to work full time (i.e hours) unless a formal job share arrangement exits or specific individual arrangements have been made. 8. Matrons will predominantly work as above with the same stipulation. 9. Other specialist areas in the Trust e.g. Emergency Department, Admission Suite, have agreed establishments and staffing levels which have been negotiated on an individual basis. 10 Each Community setting e.g District Nursing, Health Visitors has agreed establishments and staffing levels which have been negotiated on an individual basis. 11. All Wards and Departments will have a percentage allocation for annual leave, study leave and recognition of sick leave. This will be 20% as standard. Maternity currently 27.% 12. Ward Sisters, Matrons, & Directorate Managers will be involved with Heads of Nursing in agreeing staffing changes. These need to be presented and agreed with the Trust Board. 13. Each Directorate will identify a Safer Nursing Care Tool (SNCT) lead Page 5 of 14

6 to support validation and data collection. 14. Each Directorate will ensure senior nurse cover/leadership out of hours to support the PSC and ensure they actively supporting the Directorate. This will be in the form of a bleep holder arrangement Process A process of Annual review of staffing levels by Heads of Nursing has been agreed Decisions will be based upon methodology outlined in this document. More regular reviews will be agreed as required or requested, based upon service change or monitoring evidence. 1. Establishments are based upon a combination of professional judgement & scrutiny, operational knowledge, appropriate benchmarking, staffing guidance and validated acuity/dependency trend data. 2. Monthly Clinical Assurance Tool (CAT) data will contribute to the decision making. Vacancy numbers and other recruitment information will be monitored by this tool. This information will be presented to Board each month with an analysis to enhance discussions. 3. In some specific circumstances, an over recruitment may be agreed. These agreements are designed to ensure that it is possible to remain at establishment (or as close to establishment as possible and to minimise the vacancy rate) primarily where funded establishments contain high numbers of band 5 nurses. They are both agreed and monitored by Recruitment Control (RCG) process and should not incur additional cost Process for addressing short term staffing shortages including areas of responsibility and escalation process Every Ward and department has a band 7 Sister/Charge Nurse who is responsible (supported by the Matron) to ensure safe and equitable staffing levels. Table 1 below highlights the role of various senior nurses in ensuring short term staffing deficiencies are addressed. Ward Sister / Charge Nurse Lead Midwife/ Nurse in Charge of Shift Daily Short term Respond to unplanned changes to Produce monthly nursing roster to staffing i.e. sickness. The ward Sister Trust standard using 20% should take the lead and must take a headroom effectively. Identify proactive approach to ensure that areas Nurse in Charge. Monitor planned are appropriately stated. and actual staffing. Respond to changing Patient acuity / dependency. Report via Datix any staffing issues, which affect patient care. Request bank/overtime replacement where nursing shortages in planned roster are identified. Liaise with PSC re timing of elective Page 6 of 14

7 After handover or during staffing briefings consider are there any nurse staffing issues. Does the available staff meet the needs of the patients and emergency admissions Matron / Senior Midwife Daily Re allocate staff across area of responsibility to ensure safe levels throughout. Liaise with PSC regarding allocation of elective patients to other areas and liaise with other Matron s to identify any staff support available. Liaise with PSC to review the time and destination of elective admissions to identify alternative safe admission time and destination. Escalate to Directorate Manager and if necessary to Head of Nursing when unable to ensure safe level of staffing. Short term Review and revise monthly rosters, ensuring 20% headroom managed effectively to support safe staffing which is planned in advance. Monitor by Ward/department actual and planned staffing by week and summarised by month via CAT Weekly workforce planning across Directorate to ensure staff are distributed according to clinical need. In the event that staffing shortages are not resolved ensure plan is communicated to all relevant parties i.e. PSC, Head of Nursing, on call Consultant. Review clinical activity on Ward; collaborate with Directorate manager and Head of Nursing when considering cancelling elective admissions or bed closure. Monitor Datix staffing reports. Monitor nurse staffing in conjunction with the DM. Provide support and professional advice in agreeing staffing levels and skill mix as well as when escalation is required external to the Directorate Newcastle Hospitals & Community Staff Bank supply temporary staffing solutions to support Wards & departments. This may be in a planned requested way or as a solution to unplanned short term absence. Page 7 of 14

8 In the event of unexpected staff shortages out of hours please refer to flow chart in Appendix Process for provision of Specials Specials applies to the use of staff to care for patients who require additional support to mitigate risks for example related to confusion, agitation, falls risk and mental health needs. Once a patient has been assessed by the Nurse responsible for their care as at risk requiring additional nursing support use criteria in Appendix 2. to decide what level of support is required. All requests should be routinely agreed by the Ward Sister/Charge Nurse and signed off by Matron. (Out of hours the Patient Services Coordinator). Additional guidance is available in the Restraint Policy Specific guidance in relation to Mental Health observations is available in policy the above policy from June For patients who have identified mental health needs and require specialing as part of a specific plan of care, additional staffing may be requested from Northumberland Tyne & Wear (NTW) NHS FT Bank. These requests will be managed in office hours via the Trust Staff Bank and out of hours by PSC. NTW have an SLA in place with Primary Care Recruitment to supply staff in these specific circumstances. Mental Health Specials should not be booked by any other route. External Agency use is not routinely used within the Trust and must be agreed by the Nursing & Patient Services Director or designated deputy, e.g. Head of Nursing. 5.4 Process for addressing longer term staffing shortages Departments are required to both manage and monitor staff absences and the recruitment process on a very regular basis. The Nursing and Midwifery Recruitment and Retention Group supports this. Directorate Mangers are responsible for the safe staffing of all care environments; this is delegated to the Matrons. Changes to establishments must be professionally agreed with the Director of Nursing & Patient Services. Matrons discuss staffing issues and workforce planning with Heads of Nursing / Midwifery/Patient Services at regular 1:1 meetings. 5.5 Supervisory Status of Senior Ward Sisters Senior Ward Sisters have been widely identified as being crucial in influencing the standards of care delivered to patients, and for providing clear clinical and managerial leadership to their teams. This Trust has recognised the essential contribution of this role and has made provision for senior sisters in some areas to be supervisory. The amounts of time allowance will vary between but not usually within Directorates. Page 8 of 14

9 In this context the Supervisory Role (or element of this) means that Senior Sisters are not counted in the numbers on a shift to provide direct clinical care to a group of patients, but will work in a co-ordinating and leadership capacity. This will vary from Ward to Ward, but may include: being the shift coordinator; working alongside staff in a supportive educational role; conducting observational audits; completing administrative duties; addressing patient concerns. The supervisory role enables the sister to manage their workload flexibly to meet the needs of their Ward. In the context of addressing staffing shortages it enables the sister to plan ahead for this where possible, or to step in at short notice to assist on the Ward. (This should be for limited periods of time only.) The relative amounts of supervisory time vary between Specialities, the absolute minimum being 20%, i.e. one day each week. 6 Training All Sisters as part of their induction to the role will be provided with information from Matron regarding the SNCT, budgets, staffing establishments to ensure that they are equipped with the knowledge and skills to manage their nursing resource effectively. This will be augmented by Sisters/Charge Nurses attending the in house Development Programme. All adult istered Nurses receive dementia awareness, and falls risk training and should be aware of specials guidelines. 7 Equality and Diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed. 8 Monitoring Standard/process/ issue The Clinical Assurance Tool and associated staffing and Nurse sensitive indicator data is measured and monitored Results are available to Ward Sister/Charge Nurses, Matrons, Directorate Mangers, and the Heads of Nursing / Patient Services and are reported SNCT is captured as trend data as above, and respond in CAT (effective April 2014) Monitoring & Audit Method By Committee Frequency Via CAT Nursing & Patient Monthly and Patient Services Board Services And Trust reports Director to Board Board. One week each month Page 9 of 14

10 9 Consultation and Review This policy has been developed in consultation with the Senior Nursing and Midwifery team. The person responsible for reviewing the policy is the Head of Nursing RVI, the review will be performed annually or when there is a significant change, i.e. national recommendation. 10 Implementation (including raising awareness) The Strategy will be discussed at Matron and Clinical Leaders Forum. Clinical Leaders will be asked to download Appendix 1 complete it and display for staff to see. 11 References Francis Report (2013) Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 March 2009 National Quality Board Guidelines (2014): 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 RCN (2006) Setting appropriate Ward nurse staffing levels in NHS acute trusts. RCN (2010a) Guidance on safe nurse staffing levels in the UK. RCN (2010b) RCN policy position: evidence based nurse staffing levels. RCN (2012a) Safe staffing for older people s Wards: RCN full report and recommendations. RCN (2012) Mandatory Nurse Staffing Levels RCN (2013) Defining staffing levels for children and young people s services. RCM Working with Birth-rate Plus (2010): How this midwifery workforce planning tool can give you assurance about quality and safety The British Association of Critical Care Nurses (2009): Standards for nurse staffing in critical care. The Paediatric Intensive Care Society 4 th ed (2010): Standards for the Care of Critically Ill Children The Association for Peri-operative Practice (2014): Staffing for Patients in the Perioperative Setting BAPM 3rd edition (2010): Service Standards for Hospitals Providing Neonatal Care National Network for Burn Care (2013): National Burn Care Standards Care in local communities DoH (2013): A new vision and model for district nursing Recommendations of the National Renal Workforce Planning Group (2002): The Renal Team A Multi-Professional Renal Workforce Plan For Adults and Children with Renal Disease The Shelford Group Safer Nursing Care Tool (2013): implementation pack Page 10 of 14

11 The Queens Nursing Institute (2014): The District Nursing Workforce Planning Project Literature Review NICE SG1(2014) Safe staffing guideline for nursing in adult inpatient wards in acute hospitals RNM (2009) Staffing Standards in Midwifery Services. 12 Associated Documents Electronic Rostering & Attendance Policy Restraint Policy Page 11 of 14

12 Appendix 1 Agreed Nurse Staffing 2014 The following information is from the Nurse Staffing Review of your area and has been agreed with the Directorate Management Team. Your Establishment will be reviewed alongside other key performance indicators six monthly or if a service review is required by the Matron and Head of Nursing. Hospital Site Ward Number of Beds Name of Sister / Charge Nurse Amount of Supervisory time included in Establishment Agreed Establishment in WTE Agreed percentage of istered Nurses The funded establishment allows 20% uplift this allows for 3% training, 14% annual leave and the Trust target of 3% sickness and should be used as a guide when authorising holidays and study leave. E.G. Ward x which has an establishment of wte can allow 4.2 wte annual leave at any one time (14 divided by 100 x 30wte = 4.2wte) The Trust guide for Percentage of istered nurses is 55% istered in Rehabilitation areas and 60% in Acute areas, this may vary from Ward to Ward. The number if planned staff per shift is a guide to the number of staff including Sister and Housekeeper who you can have on duty with your funded establishment please include all staff providing Clinical Care. You may vary this according to the days of the week so is intended as a guide This is intended as a guide, your off duty may vary to planned numbers. Number of staff per shift Monday Tuesday Wednesday Thursday Friday Saturday Sunday E L N Hours per shift Monday Tuesday Wednesday Thursday Friday Saturday Sunday D N Page 12 of 14

13 Nurse Staffing Escalation Guide Page 13 of 14

14 Appendix 2 Criteria for requesting a special or 1:1 Nursing The Newcastle upon Tyne Hospitals NHS Foundation Trust has a duty of care to ensure the safety of patients in its care and takes all possible steps to do so. Any request for a nurse special must be discussed with Matron within working hours or out of hours initially with the Directorate bleep holder. If the decision cannot be supported within the Directorate - for out of hours the Patient Services Coordinator (PSC) should be contacted. Information is required of the following risks that are indicated and must be taken into account. Guidelines for nurse s specialing individual patients can be found in the Restraint Policy. Physical health conditions Delirium at risk of causing harm to themselves or others. Confusion Frequent attempt to mobilise where they may be a danger to themselves Cognitive impairment Dementia Risk of absconding Dignity Aggression towards other patients and staff Frequent attempt to mobilise where they may be a danger to themselves Risk of Falls High risk of falls Frequents attempts to mobilise where they may be a danger to themselves At risk of sustaining harm. Current staffing levels and number of other patients at risk on the ward must be discussed and whether cohort nursing has been considered. Following agreement all requests for a nurse special must be made through the Nurse Bank. The need for the special must be reviewed every shift Page 14 of 14

15 The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. PART 1 1. Assessment Date: 13/08/ Name of policy / strategy / service: Nurse Staffing Strategy 3. Name and designation of Author: Liz Harris Head of Nursing RVI 4. Names & designations of those involved in the impact analysis screening process: Liz Harris Head of Nursing RVI 5. Is this a: Policy Strategy X Service Is this: New X Revised Who is affected Employees X Service Users X Wider Community 6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and pasted from your policy) The strategy sets out the principles that underpin safe Nursing and Midwifery Staffing. It describes the methodology undertaken to agree funded nursing and midwifery establishments, skill mix, and the process for monitoring and review of staffing. 7. Does this policy, strategy, or service have any equality implications? Yes X No If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons: The policy covers the process for Nursing and Midwifery staffing and establishment setting as a whole rather than individuals.

16 8. Summary of evidence related to protected characteristics Protected Characteristic Race / Ethnic origin (including gypsies and travellers) Sex (male/ female) Religion and Belief Sexual orientation including lesbian, gay and bisexual people Age Evidence, i.e. What evidence do you have that the Trust is meeting the needs of people in various protected Groups Equality and diversity policy and training. Interpreter policy Patients are able to request same sex practitioners where this is required in relation to personal and sensitive care Where staff are required to support patients attending religious services staffing levels take this into account. Policies which include respecting cultural and religious beliefs. Chaplaincy service and access to other faiths provision of place to pray Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date) No No No None No No This policy takes into account the staffing requirements for working RCN recommendations for staffing ratios for children and older people have been taken into account when agreeing Does the evidence highlight any areas to advance equal opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date) Communicating with patients needing communication support such as interpreting will take longer. If there are a number of patients in one area requiring interpreters this needs to be taken into account. No No No

17 Disability learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section with children and older people Dementia strategy and adjustments Disability Care pathway Learning Disability flagging; passport and liaison nurse. BSL Interpreting Mental health observation policy Reasonable adjustments for patients and staff staffing establishments. Some patients will require additional care in relation to their disability. These will be identified through patient acuity / dependency tools and considered when reviewing staffing. No Gender Re-assignment None No No Marriage and Civil None No No Partnership Maternity / Pregnancy Staffing levels for pregnancy; delivery and post natal care are taken into account in the policy Maternity Paternity leave. Royal College of Midwives guidance has been considered when agreeing staffing ratios in relation to pregnancy; delivery and post natal care. This is taken into account in the policy. No 9. Are there any gaps in the evidence outlined above? If yes how will these be rectified? No 10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer. Do you require further engagement? Yes No x 11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and family life, the right to a fair hearing and the right to education?

18 No; this will help to prevent degrading care that can result from poor staffing levels. PART 2 Name: Liz Harris Head of Nursing RVI Date of completion: 13/08/2014 (If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)