National publication of inpatient nursing staffing

Report to: HPFT Board Date: 26 June 2014 Report by: Mary Mumvuri (Head of Nursing and Patient Safety) Subject: Nature of Report National publication of inpatient nursing staffing Open 1. Background This report serves as the six monthly review of nursing staffing for the Board in line with the requirements set out by the National Quality Board (NQB). The NQB laid out its expectations of Provider and Commissioning organisations to publish nursing and midwifery staffing in their guidance called How to ensure the right people, with the right skills are in the right place at the right time. The guidance followed recommendations from the Francis report and other high profile national reviews such as those by Prof Sir Brice Keogh, the Cavendish Review and Don Berwick s review into patient safety in England. Contained in this report are summary details of the NQB expectations, the actions taken by the Trust so far and the national and local reporting requirements. It further provides data on direct care staff fill rates for Registered Nurses and Health Care Assistants for the month of May, broken down by day and night shifts, in addition to setting some context on the published data. Finally, the report provides an update on the process applied in reviewing nursing establishments between October 2013 and May 2014, the current shift plans, vacancies and associated recruitment programmes. Expectations from NQB The NQB set out 10 expectations, 9 of which are relevant to Provider organisations and broadly cover the following areas: Accountability and responsibility of Boards Evidence based decision making Supporting and fostering professional environment Openness and transparency, Planning future requirements Role of Commissioning 1

Below is a summary of the expectations and the actions that have been taken by HPFT: EXPECTATION 1 - Boards take full responsibility for the quality of care provided to patients, and as a key determinant of quality, take full and collective responsibility for nursing, midwifery and care staffing capacity and capability. This requires Boards to ensure that there are robust systems and processes for receiving assurance about adequacy of staffing capacity and capability to deliver high quality care and that this monitored on an on-going basis through reports to the Board in order to have a deeper understanding on the impact on quality and clinical outcomes. In practice, this requires Boards to request and receive papers on establishments reviews carried out at least six monthly, with consideration and discussions at a public Board meeting. Further exception reports to the Board are expected to also be published on a monthly basis and uploaded onto NHS Choices. A nursing staffing review was included in the annual nursing strategy report that was presented and accepted at the public Board meeting in October 2013. This is therefore the second report in response to the 6 monthly reviews of inpatient nursing establishment. EXPECTATION 2 - Processes are in place to enable staffing establishments to be met on a shiftto-shift basis. This involves daily review of the actual staff available on a shift by shift basis versus the planned levels, and ensuring that solutions are sought to address the shortfalls. This review should occur between nursing leaders responsible for inpatient care. Included in this is the effective use of the e-rostering systems and the development and implementation of escalation policies and plans to help staff with decision making during times of increased pressure and demand. The Team Leader or the Nurse in Charge of a shift is responsible for the review of staffing levels in response to unplanned absence and unexpected demand as a result of increased acuity and level of physical dependency. The Trust e-rostering steering group provides oversight and challenge on the ineffective use of the electronic roster system with regards to planning the workforce and ensuring safety of skill mix and staffing levels. Further scrutiny is facilitated in operational service management forums. EXPECTATION 3 - Evidence-based tools are used to inform nursing, midwifery and care staffing capacity and capability. (Currently there are no evidence based staffing tools that have been validated for use in establishing staffing levels on mental health wards). Eight wards in the Trust across mental health and learning disability services were involved in piloting some of the staffing tools as part of the national development of evidence based staffing tools for these clinical areas. The Trust will continue to be involved in the refinement and further testing of these staffing tools. The tools that were piloted included the NHS Scotland mental health tool and Dr Keith Hurst s tool for mental health and learning disability settings. Feedback from Team Leaders who were involved in the pilot indicated a preference for the Keith Hurst tool because of its ease of use and the fact that its elements appear more sensitive to mental health and learning disability environments. Furthermore, it provided staffing levels that were consistent when professional judgement and knowledge of local services was considered. Experience of using the NHS Scotland tool was that it was useful for predicting future demand as part of new service developments. EXPECTATION 4 - Clinical and managerial leaders foster a culture of professionalism and responsiveness where staff feels able to raise concerns. Post Francis Inquiry, staff have become more aware of the need to highlight staff shortages by reporting this as an incident through the Risk management data base. There has been a 2

gradual increase in reported incidents of staff shortages on Datix and through whistleblowing incidents raised both within the Trust and externally. It would appear that staff are able to raise concerns regarding the adequacy of staffing in their individual teams. Where Whistleblowing incidents have been raised, they have been fully investigated and relevant action taken in relation to staffing reviews. Equally, where there are concerns about staffing, Team Leaders are able to take local action to address the gaps. This is reflected in the high fill rates as part of this data collected in the attached appendix (2). EXPECTATION 5 - a multi-professional approach is taken when setting nursing, midwifery and care staffing establishments. This requires close working relationships and ownership of responsibilities for key elements of staffing establishments for staff at different levels of the Organisation from direct care staff to Board members. The review of nursing staffing involves joint working between professional nursing leads, operations managers, Human Resources and Finance colleagues. The last establishment and skill mix review was approved by the Board last year in October and an update is contained within this report. EXPECTATION 6 - Nurses, midwives and care staff has sufficient time to fulfil responsibilities that are additional to their direct caring duties. This includes ensuring that there is sufficient time to undertake continuous professional development to fulfil mentorship and supervisory roles. It requires establishment uplifts that reflect realistic expectations on meeting training and development, planned and unplanned leave. In HPFT, all Team Leaders are supernumerary. This enables them to undertake supervisory roles and to cover shortfalls in emergency situations. The team budgets reflect 20% headroom factored in response to annual leave plans and training. EXPECTATION 7 - Boards receive monthly updates on workforce information, and staffing capacity and capability is discussed at a public Board meeting at least every six months on the basis of a full nursing and midwifery establishment review. This is similar as outlines in Expectation 1. The Board already receive a workforce report containing a number of workforce metrics. Starting from 24 June, we will provide exception monthly reports to the Board on nursing staffing, as it relates to actual numbers of staff in post versus actual number of staff used. All inpatient nursing staffing data collated within the month will be published on NHS Choices, two weeks after uploading on the Unify system. The nursing staffing data will be published alongside an integrated safety data set, providing information view from Trust, site and team level. Future exceptional reporting process needs to be agreed at the June Board meeting. EXPECTATION 8 - NHS providers clearly display information about the nurses, midwives and care staff present on each ward, clinical setting, department or service on each shift. HPFT has already taken action and implemented a standardised approach to displaying this information across all inpatient services. Details of the Nurse in Charge, names and roles of staff on duty and the planned versus actual number of staff is published on a shift by shift basis. Appendix (1) shows the template that is in use across all inpatient wards. EXPECTATION 9 - Providers of NHS services take an active role in securing staff in line with their workforce requirements. Included in this are workforce plans to ensure sufficient supply of nurses to meet patients demand, to have strategies for managing recruitment and retention and being represented at Local Education and Training Board. 3

The Trust is finalising the 5 year plan for Pre-registration commissioning, taking into account recommendations from national patient safety and quality reviews, transformation programme, attrition rates, recruitment and retention issues and workforce profile. COMMISSIONERS: EXPECTATION 10 - Commissioners actively seek assurance that the right people, with the right skills, are in the right place at the right time within the providers with whom they contract. This may of course require further discussion and negotiations about the staffing capacity to meet the demands and conditions set out in the contracts. 2. Review of nursing establishments: When new clinical services are developed or redesigned, the Trust reviews staffing arrangements as part of the change management process. These reviews are also subject to a Quality Impact Assessment which is undertaken and signed off by both the Executive Nurse and the Medical Director, a process that only concludes when robust assurances have been provided on how safety and quality of care will be maintained. Adhoc reviews are also carried out in response to concerns raised by staff or other stakeholders and relevant action taken to address the gaps. Reviews of nursing establishments for all inpatient services is also conducted routinely before the start of a financial year and an on-going basis, taking into account changes in acuity, service users needs, service model and bed numbers in order to ensure appropriate budget setting. This is a collaborative piece of work between Finance, Human Resources, operational managers and professional nursing colleagues. The attached Appendix 2 shows the revised establishments, skill mix, shift plan and vacancies since the last nursing report to the Board. Since October last year, all inpatient services have had a review of their nursing staff establishments using the Trust agreed staffing principles, combined with professional judgement and knowledge of case mix, location, internal and external environment. This was further augmented by Professional scrutiny led by the Executive Nurse and the Head of Nursing and Patient Safety and in consideration of known risks and identified mitigating actions. Where indicated, the reviews have resulted in changes either in the establishments or skill mix. In the absence of national guidance on nurse to patient ratio, the Trust agreed last year on the following best practice principles for safer staffing on inpatient wards: A minimum of 2 RNs on each shift for wards with 12 or more patients An RN to patient ratio of ration of 1:8 The first level of enhanced observations being absorbed in the team while additional observations require more staffing An all staff to patient ratio of between 1:4/5 depending on the complexity of the service All Team Leaders are supernumerary Most wards have allocated administration support that reflects the size of the ward and associated activity As part of implementing the national Nursing Strategy Compassion in Practice Action Area 5 and NQB expectations, the Trust has participated in the development and testing out of evidence based nursing staffing tools for mental health and learning disability inpatient services as previously mentioned. The tools were tested on a Psychiatric Intensive Care Unit, acute mental health wards, learning disability assessment and treatment wards, a continuing care and assessment and treatment wards for older adults. The results were shared with the national development group and the tools are being further developed. The Executive Director of Quality and Safety (Executive Nurse) is leading nationally on the Learning Disability staffing tool on behalf of the regional Chief Nurse as part of Compassion in Practice- Action 4

Area 5. This work has resulted in a systematic review of available literature to inform best practice as well as identify the gaps in research. The next stage of this work is to determine which tools may best assist Learning disability nursing, in determining safe staffing. The Director of Quality and Safety also sits on the national group for mental health nursing and the NICE group for safe staffing. 3. Inpatient nursing vacancies from end of May 2014: The table below shows the position of all inpatient direct care staff establishments and vacancies. Table 1 Staff Group Establishments In post Vacancies % vacancies Registered Nurses 387.09 336.39 50.7 13.09 Health Assistant Care 528.73 469.5 59.23 11.20 In comparison to the last published nursing review report, there were 69.78WTE vacancies for RNs while for HCA it was 75.45 WTE posts. The vacancies have been reduced through proactive recruitment. There are however on going challenges with recruitment and retention of staff to some older adults and learning disability wards and options will continue to be explored in order to address the gaps. 4. Centralised recruitment: A task and finish group was set up in December 2013 to address the issues of Band 5 vacancies across all services. The programme commenced in January 2014 and was led by the Head of Nursing and Patient Safety with support from HR colleagues and senior nurses within the Strategic Business Units. The purpose of this new recruitment programme was to ensure that there was a standardised process applied throughout the whole recruitment process and that efficiencies were made from the point of advertising, shortlisting, interviewing and checking documents post appointment. This was achieved through central declaration of all vacancies; setting in advance shortlisting panels with membership from all service areas and application of the same standards to shortlisting. This process was well supported by the Recruitment Team and led to significant reduction in the shortlisting process and enabled candidates to be notified of interviews in a timely manner. Interview dates and panels were also set in advance. Centralised shortlisting and interviewing reduced the chances of a candidate being turned down by one service and being appointed by another, which can lead to conflicting messages about the standards in place. This rolling programme has taken place twice now and further sessions are scheduled on an on-going basis. The interview process included an assessment centre to further test out literacy and numeracy knowledge and skills, particularly in relation to care planning and medicine management. A menu of standardised interview questions were also developed which are now refreshed and used on an ongoing basis. The interview process ensured high calibre candidates with the right skills and knowledge were appointed. The next step is to incorporate Trust values into the recruitment process. All vacancies continue to be dealt with through the centralised recruitment process apart from those areas that have been identified as hard to recruit. In these cases, localised recruitment has been authorised but with the use of the standardised assessment process. This has enabled the teams to fill the vacancies that they were unable to recruit to through the centralised process. All the vacancies detailed in Table (1) above are included in the rolling recruitment process with adverts continuously showing on the Trust webpage. Following the skill mix review in older adults services and the rebasing of budgets for Health Care Assistants posts, a centralised recruitment campaign was also set up. It involved close working with the Job Centre Plus, advertising on Herts Radio and recruitment from local communities to meet the demands of local services. Recruitment campaigns facilitated by nursing leaders and HR colleagues 5

were held in external venues at weekends in Stevenage, Hemel Hempstead and Borehamwood. Similar to the Band 5 recruitment, all the candidates underwent an assessment centre which involved written tests in numeracy and literacy. 5. Safe staffing monthly data publication: As part of NQB implementation plan and requirement to publish monthly inpatient nursing staffing data, the Trust submitted its return on Unify by the 10 June 2014 as set out. All Trusts data will be published on NHS Choices on 24 June and will be available to view by ward and site via the Trust website. The uploaded data consisted of planned and actual hours worked by Registered Nurses and Health Care Assistants during the day and on night duty for each ward (Appendix 3). The data showed that overall; the Trust used more actual direct care hours than planned for both RNs and HCAs, which meant that the vast majority of wards were adequately covered. Hours worked at night were more closely matched between planned and actual numbers than those during the day, with night shifts being covered adequately on the whole. There were a few outliers where the fill rates were either significantly lower or higher than the majority range. The average day time fill rates for RNs was 107% and 124% for HCAs while for night time RNs it was 100.4% and 112.5% for HCAs. The wards that stand out as having low fill rates: Below 80%: Lexden Assessment and Treatment ward had an RN fill rate of 71.8% for day time shifts. This is an 8 bedded assessment and treatment ward for service users with a learning disability and is co- located with another small learning disability recovery ward with 4 beds. The two wards are jointly managed by one Team Leader and Matron. This low fill rate was as a result of inability to cover the shifts due to short term absence, coupled with some vacancies. The adjacent recovery unit had a high RN fill rate at 135.7% and would have been able to provide additional cover if required. The Stewarts is an older adults continuing care ward and had a HCAs fill rate of 76.8% during the day. This was as a result of increased levels of observations but unlike other wards, this was not compensated by an increase in the RN cover. Between 80-90% The two wards with an RN fill rate of between 80 90% during the day were Gainsford House and Astley Court while at night time it was Prospect House, Welwyn ward and Hampden House. Fill rates in this range were also noted for HCAs on Mayflower/Vega, 4 Bowlers Green during the day. However when some of the data is considered alongside knowledge of local services, the concerns is lessened such as in the case of co-located wards e.g. QEII, Broadland Clinic and Lexden hospital. This is because of a critical mass of staff and the ability to summon for help in an emergency. Team Leaders are supernumerary on all wards and are therefore able to provide additional cover in an emergency. In most cases, the high fill rate in one staff group was counter balanced by a lower fill rate in another, thereby achieving the total number of staff required for the shift but not the agreed skill mix. Although not an ideal skill mix, the availability of more staff reduces the concerns about inadequate staff to respond to service user needs and will enable continuity of care. This is because in most cases, teams prefer to work with staff who know the service users needs than necessarily achieving the correct skill mix. Over 130% fill rate There were 14 wards that worked with a fill rate over 130%, with the highest rate being 418% (Essex ward). It is worth noting that this ward is due to close in June and relocate into a newly built inpatient facility. The ward is incurring double running costs in order to facilitate mandatory training and induction 6

into the new environment. As previously mentioned, other high fill rates were in response to increased observations levels and physical dependency. From the data analysis and discussions with Team Leaders and operational managers, the feedback is that the high fill rates are in response to increased acuity, high levels of physical dependency and challenges of managing observation in environments where there are obscure lines of sight. That said, the higher than normal fill rates need to be monitored to ensure that all available staff cover options are considered and that service users particularly on enhanced observations, are reviewed in line with policy. 6. Reporting timelines: The expectation to publish a detailed nursing staffing report as outlined in Expectation 3 will be met by discussing and considering this report at the private Board in June and making the report available on the Trust website with a link to NHS Choices. This report will be further considered and discussed at the Public Board meeting on 31 July. Monthly reporting from July onwards, an exception report will be provided to the Board that will include details of planned versus actual staffing on a shift by shift basis in addition to, workforce metric. The report will consider the impact on quality of care including the actions being taken to address the gaps. The expectation is that this report will also be published on the Trust website and uploaded on NHS Choices. Six monthly reporting The last full nursing review report was presented at the public Board meeting in October 2013 and the next one will be provided at the July meeting rather than June. This is outside of the 6 monthly reporting timeframe therefore in order to meet with the guidance expectations to publish the first report by 24 June, a report will be presented to the June private Board but made available on the Trust website and NHS Choices. The next full nursing review report will be due in December 2014. 7. Conclusion: This report has provided brief details of the NQB 9 expectations as they relate to Provider organisations as well an update on the progress made by the Trust in response to their guidance. Highlights from the data analysis, including potential hot spots and outliers are included in the summary findings, with detailed data per ward shown in the nationally published nursing staffing data available on the website and included as Appendix (3). Nursing establishments, shift plan and skill mix have been subject to a variety of reviews and scrutiny in order to provide assurance on the ability to maintain safe and quality services. There has been a significant improvement in addressing the vacancies across the services in order to ensure continuity of care. This is supported by a rolling recruitment programme. In conclusion, the Board is asked to consider the scope and detail they would like to see included in the monthly exception report in relation to nursing staffing. 7