Report for the Meeting of the Trust Board of Directors Held in Public Date of Meeting: 17 December Enclosure: 7a Title of Report Ward Nursing Team Assurance Report November Author Executive Lead Lesley Carruthers Deputy Director of Nursing Chris Platton, Acting Director of Nursing & Quality Chris Platton, Acting Director of Nursing & Quality Responsible subcommittee Safety and Quality Committee Date of paper 09 December Executive Summary This ward report provides the assurance that the ward staffing levels and monitoring of agreed indicators ensure safe care is delivered in line with Keogh. Since September all adult in patient areas, Midwifery, Paediatrics and Special Care Baby Units (SCBU) are included in the ward assurance report. This report will provide assurance to the Board of Directors on our ward nursing teams using the indicators in appendices 1 & 2. This reporting format identifies the staffing of our ward areas for both qualified and health care assistant and attempts to predict when specific ward areas are developing the potential to become problematic therefore avoiding issues by prompt intervention. Ward/Department Monitoring The wards listed below are under close supervision and monitoring by the Senior Nursing Team and Operational Service Managers due to vacancies and sickness which include; EAU WCH EAU CIC Beech A CIC Honister WCH Jenkin WCH Our Accident and Emergency Departments (A&E), Emergency Medical and Surgical assessments units across the Trust remain a concern due to the challenges with patient flow. The weekly patient flow meetings chaired by the CEO is closely monitoring the patient flow pathway however the number of community beds closed has caused further patient flow challenges for the Trust at both sites. Managers and senior nursing staff are aware that the A&E departments and assessment units may require additional support 1
when patients are required to be cared for in A&E until the appropriate speciality bed is identified. This is monitored over a 24/7 period along with all staffing shortfalls by the site coordinator, matron, OSM, manager on call and exec director on call. The actions required are identified in the sit rep report and are also discussed in the face to face bed meetings held three times a day as a minimum. Our site coordinator team have had challenges with sickness and vacancies. Shortfalls have been covered by the OSM and ward sisters. The team have also been supported by the matron and vacancies are appointed too with all staff in post by January 2014. Nurse Staffing Following the CQC judgement on the Trust of non-compliance for outcome 13 staffing and in line with the Trusts Keogh action plan the Trust has undertaken a significant review of nurse staffing across all ward areas. The detail of which was presented in October and November to Trust board. Further board development on nurse staffing is planned in January 2014 with the Trust response and plans regarding the recently published guide from the Quality Board for the Chief Nursing officer for England on How to ensure the right people, with the right skills, are in the right place at the right time- A guide to nursing, midwifery and care staffing capacity and capability. The review of nurse staffing and acuity assessment are two key priorities in the Trusts CQC and Keogh action plan. Acuity assessment provides the Trust with evidence based calculation of nurse staffing and acuity and will be repeated for a 21 day period in January 2014. No major cause for concern relating to the ward areas across the Trust for any one ward, department or team has been highlighted. Risk and Assurance Legal implications/ regulatory requirements Actions required by the Board No major concerns are highlighted. CQC Outcome 13: Staffing Keogh Report To approve the contents of the report. 2
Ward Nursing Team Assurance for November Report for the Board of Directors 17 December Purpose of the report This report is to provide assurances for the ward team standards to the Board of Directors using agreed indicators. The indicators (appendix 1) include; ward manager cover over five days, ward manager appraisal, mandatory training, qualified ratio of nursing staff, ward clerk cover, ward leadership training, ward rostering training, safety thermometer (harm free care), clinical indicators, monthly ward check and the number of complaints received by ward/department. The previous Trust Board ward assurance reports included data relating to the priority wards highlighted by Keogh and the CQC; Overwater1&2, Gable/CCU, A&E, intensive care and the acute frail elderly wards. Since September the report includes; all adult in patient wards, maternity, paediatrics and special care baby units (SCBU). Appendix 2 relates to ward staffing. This includes the number of nurses qualified and unqualified required per shift, the number of substantive staff who actually worked per shift and identifies the additional support provided from bench/bank/extra hours/agency to ensure safe staffing and skill mix. One ward manager still requires training in roster management which incorporates all aspects of shift rostering, skill mix, consistency and budget management; this training is planned for January 2014. This ward however has a member of the senior team who has completed roster training. The wards are audited monthly by the Matron for appropriate and effective completion of off duty rostering which will be reported quarterly to Trust Board. Findings Indicator RAG rating Weekly worked number November : Were our wards safe? Yes 91% in November of the adult general wards were reported as having the agreed qualified nursing numbers, ratio and skill mix. It must be noted that the use of nurse bank and extra hours were required to achieve this. The report will aim to identify the use of bank, extra hours and overtime used to maintain the ward nursing numbers. The areas where extra HCA s have been used to support wards were; CIC Beech A, EAU (Larch A/B), Elm C, Larch C, Willow A. WCH; Jenkin, Honister and EAU. The ward areas where staffing fell below 90% for qualified cover were; CIC ITU, Beech A, Elm C, 3
Larch C & D, Willow A and WCH ITU. The ward manager from Beech A is currently providing additional leadership and support to Larch A/B and a temporary ward manager has been appointed to Beech A however the backfill hours are vacant and this is requiring daily monitoring by matron and OSM. A plan is in place to backfill this temporary measure with an agency qualified nurse with a pre-arranged agreed time period to ensure continuity. Vacancies are monitored by the Deputy Director of Nursing (DDoN) at the weekly vacancy and rota review meetings with the Chief Matron to minimise risk and ensure patient safety. Serious Incidents & Complaints/Serious Case Review: No major nursing team concerns involving the wards and departments for areas reported in this report have been expressed by the Medical Director or Director of Nursing when signing off investigations. CQC Action Plan Cumberland Infirmary & West Cumberland Hospital The acute frail elderly ward managers are on track with actions they have identified in response to the CQC unannounced inspections in March and May and presented their work to Trust Board in June and October. This work is being rolled out across medicine and surgical wards. A follow up unannounced inspection of both sites by the CQC was undertaken in September and the CQC reports published in October. The CQC reports were presented to Safety and Quality Committee in November. The unannounced inspections in September reviewed progress on the outcomes and judgements inspected in April and May. The following CQC outcomes were reviewed: Outcome 4 - Care and welfare of people who use services Outcome 13 - Staffing Outcome 21- Records The table below shows the CQC judgement received in April and May and the judgements from the September inspection; Outcome Care and Welfare CIC March CIC September WCH May WCH September Moderate Minor Moderate Minor Staffing Major Moderate Moderate Minor Records Major Moderate Minor Fully Met We will continue to report and monitor progress on the Trusts CQC action plan and the 15 steps assessments on ward areas. Trust Board will continue to receive updates and presentations from the clinical teams on progress made. The surgical ward managers are to present to Trust Board 4
December on actions taken to date and plans in place. Director of Nursing Standards: The chart in Appendix 1 covers; ward manager cover over five days; ward manager appraisal; mandatory training; ward leadership training; qualified ratio of nursing staff; ward rostering training; RN bed ratio; ward clerk cover; safety thermometer; clinical indicators; monthly ward check; number of complaints. The chart in Appendix 2 covers; Appendix 3: staffing levels Qualified/Unqualified; staffing numbers required Qualified/Unqualified; Qualified shifts covered; Bench/bank/extra hours/agency used; Sickness; Vacancies; Instances when staffing numbers correct. Nursing Standards Assessment Tool In October the current vacancies were 2.9% for qualified nursing staff across the Trust and the November figures are currently being validated. The medical business unit continue to have a high number of vacancies and have in place a rolling advert for qualified staff. All nurse vacancies are monitored weekly and reviewed by the Deputy Director of Nursing. On-going recruitment however continues to be a challenge; the Trust is currently working with the Cumbria Partnership Trust regarding exploring rotational posts and the Trust Development Authority with overseas recruitment. 5
A. Summary There is cause for concern with the increased number of emergency admissions across the Trust. This is being closely reviewed and monitored by the CEO and the Medical and Surgical Business Unit Directors AND Deputy Directors. This is causing increased pressure on our staff in Accident and Emergency Departments and Emergency assessment units. A weekly patient flow meeting is in place led by the CEO however the number of community beds closed has caused further patient flow challenges for the Trust at both sites. On-going recruitment continues to be a challenge; the Trust is currently working with the Cumbria Partnership Trust regarding exploring rotational posts and the Trust Development Authority regarding overseas recruitment. Larch A/B and Pillar Patterdale (EAU), Beech A, Jenkin and Honister wards continue to require close monitoring and ongoing support due to sickness and vacancies. The ward manager from Beech A is currently providing additional leadership and support to Larch A/B and a temporary ward manager has been appointed to Beech A, however the backfill hours remain vacant and this is requiring daily monitoring by matron and OSM. A plan is in place to backfill this temporary measure with an agency qualified nurse for a pre-arranged agreed time period to ensure continuity of staffing. The acuity review will be repeated in January and June 2014 along with a review of the professional judgement and reported to Board. No major cause for concern relating to the ward areas across the Trust for any one ward, department or team has been highlighted. C Platton Acting Director of Nursing L Carruthers Deputy Director of Nursing 13 December 6
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