Safer Staffing Nursing and Midwifery Workforce Information January 2015 Report 1. Purpose: The purpose of this report is to provide the Trust Board with an update on the status of nursing and midwifery staffing levels at the Royal United Hospital Trust for the month of January 2014. The report forms one of the compliance requirements, against the National Quality Board s standards which are highlighted in How to ensure the right people, with the right skills, are in the right place at the right time (National Quality Board, November 2013). The following report provides an overview of the nurse, midwifery and care staff fill rate in hours planned versus actual. It aims to provide the Board with assurance around nurse staffing by detailing the reasons why inpatient areas are either under or over their planned staffing hours and what actions are in place to address any gaps or over establishment. The report also appraises the Board of those wards that require close monitoring and attention in light of their staffing levels and quality matrices. 2. Scope of the Review This report is focused on all in-patient adult wards including critical care and all in-patient maternity wards on the acute site as well as the inpatient community birthing centres. This monthly report is submitted as part of the National Quality Board requirements which includes publishing nurse staffing data both on the Trust website and NHS Choices website. The Trust is required to report on the actual staffing numbers for inpatient areas (in hours) against planned staffing levels for each month. Since May 2014 the trust website safer staffing page (URL: www.ruh.nhs.uk/saferstaffing ) is available to sign post the public to the monthly staffing information to ensure transparency and compliance with national requirements. 3. Safer Staffing Trust overview The Trust s overall average staffing hours fill rate, planned versus actual for Registered Nurses (RN) and Registered Midwives (RM) and Health Care Assistants (HCA) for the day and night shift for January was: January 2015 Day shift Night shift Ave fill Ave fill rate HCA Ave fill Ave fill rate HCA RUH 91.3% 100.4% 94.6% 106.9% Chippenham (Birthing Suite) Paulton (Birthing Suite) 100% 100% 100% 100% 100% 100% 100% 100% The overall gap in fill rates for RNs both day and night shifts reflects the number of vacancies and sickness and inability to fully cover the shortfall. The additional fill rates for HCA care staff particularly at night reflect the additional HCAs deployed to cover RN vacancies and patients who require Specialling. Agenda Item: 10 Page 1 of 8
3.1 Reporting by Exception Ward level data The current method of collecting actual staffing data against planned establishment is undertaken through ward staff inputting their rotas into the Roster Pro database. Trust wide this is overseen by the Staffing Solutions Manager and also includes the inputting of temporary staffing either Bank or Agency. The planned staffing levels are those that have been approved at budget setting and with the Director of Nursing and Midwifery and are against evidence based skill mix reviews and benchmarking. The planned staffing levels are the budgeted establishments. The full overview and summary of the average percentage fill rates based on staffing levels planned and actual (calculated in hours) of the registered nurse/midwife and non-registered nurse/midwife (called in the national template Health care assistants) for all inpatient wards for the month of January is provided in Table1. Table 1 (overleaf) highlights areas where the average actual staffing hours fall < 90 per cent fill rate (Red) or are > 120 per cent fill rate (Blue). Where there are fill rates either side of these ratios explanations are provided and where necessary any actions that are being taken to address any shortfall or over establishments. These data forms part of the data collection that is published via UNIFY and uploaded on NHS Choices web pages. This month the number of day and night shifts RNs and HCAs which were identified as being outside of the set parameters <90% and > 120% are fairly static at 40 shifts from 39 shifts last month. However, the fill rate % for many shifts is still improving, despite these shifts being outside the set parameters and this reflects progress with our Recruitment and Retention Action Plan. The Recruitment and Retention Action Plan is monitored via the Nursing and Midwifery Workforce Planning Group monthly. Agenda Item: 10 Page 2 of 8
Safer Staffing Report - January 2015 Table 1 Day Night Ward Name rate CA rate - CA Explanation and Actions taken where fill rate <90% or >120% ACE 89.5% 89.1% 78.2% 87.8% Acute Stroke Unit 90.8% 80.2% 95.4% 106.4% Cardiac Ward 82.3% 89.1% 87.3% 117.3% RN and HCA shortfall due to sickness and HCA vacancies. Sickness is being actively managed. Patient acuity and dependency was such (lower) that staff were deployed to support other wards where the acuity/dependency was higher. Shortfall of HCAs day hours are due to long term sickness. Sickness is being managed within the Trust s Sickness Policy. RN hours shortfall day and night is due to both long and short term sickness and vacancies. Sickness being actively managed and vacancies been appointed but not yet in post. Charlotte Ward 92.9% 114.0% 101.4% 96.4 % Cheselden Ward 106.5% 123.8% 100.0% 116.1% Children s Ward 88.1% 115.0% 102.7% 93.5% Combe Ward 82.7% 116.8% 104.4% 138.5% Coronary Care Unit 88.5% 95.0% 100.0% 93.7% Forrester Brown Ward 99.2% 104.3% 97.6% 121.7% HCA numbers increased due to extra 6 beds opened for escalation and patients requiring specialling. RN day shortfall in the day due to vacancies, sickness and maternity leave. Recruitment is being actively managed. HCA numbers increased during day to offset RN shortfall. There are RN vacancies which are presently being recruited. Additional HCA hours (Day and Night) cover RN gap in the day as well as patients who require Specialling at night. RN shortfall on days due to vacancies and sickness. Vacancies will be fully recruited by February. Sickness being managed. Additional night HCA hours support patients requiring Specialling. Agenda Item: 10 Page 3 of 8
Day Night Ward Name rate CA rate - CA Explanation and Actions taken where fill rate <90% or >120% Haygarth Ward 85.4% 82.8% 97.0% 96.9% Helena Ward 115.1% 119.5% 90.3% 120.7% Intensive Therapy Unit 93.9% 122.2% 89.9% 167.7% Medical Assessment Unit 95.3% 108.3% 91.3% 101.7% Medical Short Stay 88.4% 95.3% 97.9% 102.3% Midford Ward 83.9% 84.2% 85.6% 102.2% Neonatal Intensive Care Unit 72.5% 118.3% 100.0% 75.8% Parry Ward 92.3% 98.7% 101.3% 105.5% RN and HCA day hours shortfall due to vacancies which are being recruited. RN shortfall at night but additional HCA hours cover shortfall. Additional HCA hours were also booked for patients requiring specialling at night. Shortfall of RNs on the night shift due to sickness, Band 4 non- Registered nurses compensated the shortfall. Additional HCA hours (days and nights) due to the number of overseas nurses still awaiting NMC Registration. Some additional hours at night recorded were new staff in a supernummary capacity, which should not have reflected in this data. This will be rectified next month. RN day shortfall was due to long term sickness, vacancies and staff being deployed to other wards. RN shortfall due to vacancies and sickness and HCA shortfall day hours due to sickness. Short term sickness resolving and active recruitment on-going. Shortfall with RNs days and Nursery Nurses both day and night is due to sickness and vacancies. Additional hours of Nursery Nurses met the shortfall of RNs during the day. Actively recruiting and staffing levels met the acuity and dependency of the Unit at the time. If required staff were deployed from Children s Ward. Agenda Item: 10 Page 4 of 8
Day Night Ward Name rate CA rate - CA Explanation and Actions taken where fill rate <90% or >120% Phillip Yeoman Ward 97.0% 107.4% 98.8% 87.4% Pulteney Ward 93.6% 97.4% 95.8% 109.0% Respiratory Ward 75.2% 128.4% 77.9% 154.0% Robin Smith Ward 85.3% 95.4% 102.1% 107.1% Surgical Admissions Unit 89.2% 111.6% 120.5% 81.6% Surgical Short Stay Unit 84.0% 109.1% 98.8% 184.9% Waterhouse Ward 100.8% 109.5% 99.9% 99.5% William Budd Ward 100.4% 94.5% 101.4% 108.1% Mary Ward 102.6% 73.2% 91.0% 86.0% Paulton Birthing Centre 100.0% 100.0% 100.0% 100.0% Chippenham Birthing Centre 100.0% 100.0% 100.0% 100.0% The shortfall of HCA hours at night reflects the patient acuity and dependency that is required for their planned elective surgical activity. The activity reduces at the weekends when staffing numbers are lower than planned. There are RN vacancies and sickness hence a shortfall during day and night. RNs are being recruited although not yet in post. Additional HCA hours cover the RN shortfall. The RN shortfall in the day was due to vacancies and short term sickness, both of which are being managed. Shortfall in RN day hours and HCA nights were due to vacancies and sickness. The additional RN hours at night supported additional inpatients at night to manage extra inpatients in escalation. RN shortfall during the day is due to mainly sickness. Additional HCA hours are deployed for extra beds as they are opened in escalation overnight. Sickness being managed. HCA shortfall nights and days due to vacancies and long term sickness. Actively recruiting and managing sickness. Agenda Item: 10 Page 5 of 8
3.1 Areas of Focus Following a review of the Trust Board Quality Report FFT Triangulation report (Appendix ) which identifies Wards where staffing levels have been < 90% fill rate and they appear to have had a detrimental effect on quality matrices, this month two wards appear to feature. Last month three wards were deemed to require attention, these being: Respiratory ward Pulteney Ward (Older Persons) Midford Ward (Older Persons) On review of the Triangulation report both Respiratory Ward and Pulteney Ward have improved their staffing levels and quality matrices and therefore have not flagged this month. Midford ward has flagged, which is two months in a row; however the quality matrices and staffing levels fill rate have improved. Midford Ward (Older persons) This ward has RN vacancies and their RN hours % fill rate both day and night is < 90% at RN fill rate 83.9% (day ) and RN fill rate 85.6% (night), although showing some improvement on last month. The HCA % fill rate in the day was also < 90% at HCA fill rate 84.2%, this being due to sickness. This 28 bedded ward continues to have two additional beds opened in escalation. These beds are side-rooms in a corridor away from the main bedded areas and will have been additional workload for the nursing staff. The quality matrices in the Trust Board Quality Report, Triangulation report (Appendix ) of note are: FFT score % recommending RUH 89% (85% last month) Nil C.Diff (C Diff x1last month) Falls x 3 (1 negligible and 2 minor) (10 Falls last month) The Matron and Head of Nursing will continue to monitor the ward and quality matrices to determine if any further actions need to be put into place. The senior nursing corporate team are undertaking some observed visits to the ward to gain assurance about quality. They will aim to close the additional escalation beds as soon as possible. ACE Ward (Older Persons) This ward flagged for the first time this month as requiring attention due to its staffing levels where the RN and HCA average % fill rate was < 90% in every shift. The quality safety matrices also registered although not significantly high and their FFT score was 100% recommending RUH. The quality matrices in the Trust Board Quality Report, Triangulation report (Appendix ) of note are: Complaints x 1 and PALS negative contacts x 4 Falls x 6 (3 negligible and 3 minor) Appraisal rate for HCAs only 69.2% Authors: Jan Lynn, Lead Nurse, Workforce Development and Education Agenda Item: 10 Page 6 of 8
The Head of Nursing states that the staffing levels on this ward would have been > 90% however due to the patient acuity and dependency on the ward, the Senior Sister was able to deploy staff to other wards which were deemed to have Red staffing levels and requiring additional nurses to support patient care delivery. The Matron and Head of Nursing will however monitor the ward closely and the quality matrices to put any necessary actions into place if required. 4.0 Daily staffing Staffing levels each shift are managed via a Nurse Staffing Escalation Policy within the Divisions and with close support from Staffing Solutions who assist with the priority of allocating temporary staffing each shift. This is supported by a Matron or Head of Nursing who, using professional judgement, determine the level of staffing required according to the patient s needs. A Red, Amber, Green (RAG) rating system has been developed supported by Staffing Solutions which gives a shift by shift Trust wide overview of all the wards to support this decision making and prioritisation. Over the New Year period the Escalation Policy was enacted and nurses were deployed from wards where the patient acuity and dependency was such that nurses could be deployed to other wards that were short. Also Corporate Nurses e.g. Qulturum and Education Centre were deployed to support those wards where staffing levels were deemed to be Red to maintain good quality care for patients. 5.0 Nursing Recruitment Recruitment activity still continues and the vacancy rates are still reducing, although there is a time lag to when the nurses start their employment with the Trust. The Nursing and Midwifery Recruitment and Retention Action Plan is in place and is progressed by the Nursing and Midwifery Recruitment Sub-group. This is monitored and reported to the Nursing and Midwifery Workforce Planning Group which meets monthly and is chaired by the Director of Nursing and Midwifery. 6. Summary of exception report Safe staffing levels are managed on a daily basis and a robust escalation process is in place. Ward Sisters and Matrons review inpatient ward areas on a shift by shift basis taking any required actions and escalating issues to the Heads of Nursing and Senior Nurse Team to ensure safe staffing is in place to meet patient s needs. The focus on nurse recruitment continues to be a high priority in view of the registered nurse vacancies across the Trust. Following review of the FFT Triangulation Report, generally the quality and safety matrices have improved. Authors: Jan Lynn, Lead Nurse, Workforce Development and Education Agenda Item: 10 Page 7 of 8
Two wards flagged this month as requiring attention, one of which flagged last month as requiring attention (Midford Ward), however their quality matrices and staffing levels have shown good signs of improvement. ACE Ward, whilst it appeared to flag on the Triangulation report, the Senior Sister and Head of Nursing deemed the staffing levels to be sufficient for the patient acuity and dependency and supported other wards by redeploying staff. Their quality and safety matrices were also not significantly poor and their FFT score was 100%. Overall and for the last two months there has been some slight improvement in the staffing levels fill rates which reflects the improvement with recruitment and retention. 7. Conclusion This report provides an overview in relation to safer staffing requirements and delivery in the Trust. Divisions have been monitoring, reporting and taking action in relation to safer staffing on a shift by shift basis. Safer staffing is viewed alongside a wide range of other indicators in relation to patient safety and outcomes. This information will continue to be published on a monthly basis on the Trust intranet and via NHS Choices. 8. Recommendation The Board is asked to note the contents of this report and the mitigating actions being taken to address any gaps in the nursing workforce at ward level. Authors: Jan Lynn, Lead Nurse, Workforce Development and Education Agenda Item: 10 Page 8 of 8