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TRUST BOARD26 May 2016

AGENDA ITEMNUMBER

6.3

TITLE OF PAPER Safer Staffing Levels

Confidential NO

Suitable for publicaccess

YES

PLEASE DETAIL BELOW THE OTHER SUB-COMMITTEE(S), MEETINGS THIS PAPER HAS BEENVIEWED

None

STRATEGIC OBJECTIVE(S):

Best outcomes √ Expectation 2 and 7

Excellent experience √ Expectation 2 and 7

Skilled & motivatedteams

√ Expectation 2 and 7

Top productivity √ Expectation 2 and 7

EXECUTIVE SUMMARY

This paper provides a review of the safer staffing levels within inpatient areasin Ashford and St Peter’s Hospitals NHS Foundation Trust for April 2016 inaccordance with the national reporting requirements and guidelines.

The Trust continues to follow its policy on safer staffing escalation, thussupporting the delivery of safe, high quality care.

Both the establishment performance by shift, together with the planned versusactual staffing levels have been triangulated with ward-level qualityperformance and evidence of mitigation where required.

There is still a challenge to consistently meet safer staffing levels, however,risks are constantly being mitigated through daily actions and professionaljudgement.

RECOMMENDATION: To receive this paper as assurance that safe staffing data is submitted inaccordance with Safer Staffing expectations 2 and 7.

To note and seek assurance where required pertaining to the practices of the

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nursing leadership teams to ensure safer staffing is observed.

SPECIFIC ISSUES CHECKLIST:

Quality and Safety Ensuring adequate staffing levels to provide excellent care

Patient Impact Ensuring high quality staffing to provide excellent care

Employee Ensuring correct staffing levels to provide support and supervision to staff

Other Stakeholder n/a

Equality & Diversity n/a

Finance Promoting safer staffing levels and reducing reliance on agency and bankstaffing

Legal n/a

Link to Board AssuranceFramework (BAF)Principle Risk

Links to BAF risks 1.4 workforce aligned to acuity and risk 3.1 recruitment.

AUTHOR NAME/ROLE Russell Wernham, Deputy Chief Nurse

PRESENTED BYDIRECTORNAME/ROLE

Heather Caudle, Chief Nurse

DATE 13th May 2016

BOARD ACTION Assurance

1. Background and scope

ASPHFT follows an agreed methodology for reviewing nurse staffing levels on theinpatient wards. The Board requires assurance that the Trust is managing staffingcapacity and capability alongside the considerations on decisions and initiatives with theassociated accountability for these. This methodology is changing from the 1st May 2016and this report represents the last report using a percentage shift fill calculation. The newmethodology implementation narrative from NHS Improvement (NHSi) is included asappendix 4.

2. Strategic issues and options

Recruitment and retention issues

Recruitment continues overseas, alongside local initiatives.

Monitor Agency Cap

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This is reported on weekly with feedback provided to senior management.

Operational pressures

The operational pressures on the Trust during April period were significant. The staffing ofescalation areas was discussed daily and the nurses based within corporate teams wereused to support these escalation areas.

Actions to address gaps

Planned and actual staffing levels are reviewed on a shift by shift basis by the WardManager and Clinical Nurse Leader and discussed at daily Capacity Action Teammeetings.

3. Numbers

The report has used information from the e-Rostering system; the reported fill rate is

based on the number of nursing hours deployed as a percentage of the number of

nursing hours planned in the rota. The table and graphs below show the average fill rates

for April 2016 as part of a 12 month trend.

Site Day Night

Average fill

rate RN/RM %

Average fill

rate care staff

%

Average fill

rate RN/RM %

Average fill

rate care staff

%

Ashford 88.7% 99.5% 100.0% 93.3%

St Peter’s 87.4% 105.1% 88.0% 123.0%

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AcuteandEmergencyMedicineDivision:T:\WardMonitoring-WeeklyReporting\16-17

KPIs\AMES\DailyTool

Theatres, Anaesthetics,SurgeryandCriticalCare: T:\WardMonitoring-Weekly

Reporting\16-17KPIs\TASCC\DailyTool

Diagnostics, Therapeutics,Trauma andOrthopaedics: T:\WardMonitoring-Weekly

Reporting\16-17KPIs\DTTO\DailyTool

Women’sHealthandPaediatrics:T:\WardMonitoring-WeeklyReporting\16-17

KPIs\WHP\DailyTool

4. Context

Senior nursing and midwifery management at ASPH continue to monitor and report the

inpatient ward staff level. Divisional commentary is provided in Appendix 3.

Whilst on-going capacity pressures and recruitment shortages continue, there is still a

sustained vigilance over staffing levels daily, weekly and monthly and there are bespoke

projects specifically responsive to staffing issues in critical areas.

5. Impact measures and follow up

Monitoring of patient acuity and dependency using the safer staffing tool was completed in

March 2016. The next period of review will commence in July 2016.

Monitoring of Paediatrics acuity and dependency continues using the PANDA tool.

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Appendix 1 shows the Safer Staffing and Quality RAYG rating dashboard for April 2016.

6. Assurance

Maintaining safe staffing levels in the face of recruitment and retention challengesalongside high levels of inpatient activity remain a risk to the Trust. This risk is managedthrough a range of actions to address both operational and workforce issues andtherefore the Board can be assured that:

1. There is evidence that escalation of and mitigations against staffing red flags areincreasingly timely and effective.

2. Accountability of adhering to both the nursing agency caps and the safer staffing on thewards has been strengthened.

Appendix 1 Safer Staffing QEWS RAYG Rating April 2016

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QEWS

LEVEL

AandE 248 0 21 249 100 2 2 0

Aspen 90 - - 90 100 1 2

CCU &

Birch90 6 12 72 80 4 1

Cedar 90 25 37 28 31 1 2

Holly 90 8 52 30 33 1

May 90 2 18 70 78 2 1

AMU 90 10 17 63 70 1 1

Cherry 90 - - 90 100 2

Maple 90 34 19 37 41 1 2

Chaucer 90 1 - 89 99 1

Swift 90 11 23 56 62 1

Dickens 90 24 17 49 54 2

Swan 90 16 11 63 70 4 1

Kingfisher 90 13 23 54 60 1

Falcon 90 - 1 89 99 1 1

SDU 90 1 - 89 99 2

Heron 90 1 18 71 79 1 1

SAU 90 8 21 61 68 1 2

ITU 90 6 45 39 43 2

MHDU 90 1 - 89 99 2

Abbey BC 60 - - 60 100

Ash 60 0 0 60 100 1 2

NICU 240 21 25 194 81 1 2

Labour

Ward120 6 25 89 74 2

Joan Booker 120 - 25 95 79 2

T&

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Red shifts

sparkline

Apr 15 -

Mar 16

SAFE STAFFING LEVELS DATA – April 2016

Divisio

nWards Red Amber Green % Green

Ward

SI’s

Ward

Red

Flags

Total

shifts

Ac

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Appendix 2 Staffing Average fill rate with sickness, maternity and new starters April 2016

Day Night Vacancy % Sickness % Maternity Leave % New Starters Leavers

Ward name Main Specialties Average Average Average Average

Register Care Staff Registered Care Staff

Chaucer 314 - 99.2% 106.6% 100.0% 100.0% 4.1% 7.0% 2.1% 0.00 0.00

Dickens 110 - TRAUMA & 81.9% 95.2% 100.0% 86.7% 22.6% 14.1% 4.7% 0.00 0.00Aspen 340 - RESPIRATORY 100.0% 100.0% 100.0% 100.0% 1.0% 3.8% 0.0% 0.00 0.00BACU 300 - GENERAL 87.9% 161.6% 97.8% 106.7% 17.5% 3.1% 9.6% 0.00 1.00Cedar 300 - GENERAL 75.4% 102.8% 86.7% 110.0% 5.8% 3.0% 2.1% 0.00 0.00Falcon 100 - GENERAL 93.3% 132.6% 95.6% 190.0% 6.6% 3.0% 3.5% 0.00 0.00Heron 100 - GENERAL 94.8% 98.4% 100.0% 110.0% 8.6% 3.5% 0.0% 0.00 0.00Holly 430 - GERIATRIC 74.8% 105.9% 66.7% 134.4% 30.4% 5.7% 0.0% 0.00 0.00

Kingfisher 100 - GENERAL 76.3% 117.3% 64.2% 236.7% 28.9% 1.3% 3.8% 0.00 0.00Maple 300 - GENERAL 77.2% 96.2% 95.6% 101.7% 35.5% 1.8% 0.0% 0.00 0.00May 300 - GENERAL 80.1% 130.0% 73.3% 190.0% 24.0% 4.4% 4.7% 0.00 0.00SAU 100 - GENERAL 87.7% 105.5% 87.8% 120.0% 19.4% 0.9% 0.0% 1.00 0.00Swan 110 - TRAUMA & 85.1% 101.7% 93.3% 110.0% 16.9% 7.5% 8.8% 0.00 2.00Ash 420 - PAEDIATRICS 118.7% #DIV/0! 123.3% #DIV/0! -2.6% 2.0% 0.8% 0.00 0.00

Joan Booker 501 - OBSTETRICS 98.9% 82.4% 92.5% 186.7%

Labour 501 - OBSTETRICS 88.7% 113.1% 93.7% 91.7%

Abbey Birth Centre 501 - OBSTETRICS 100.0% #DIV/0! 100.0% #DIV/0!

ITU 192 - CRITICAL CARE 98.5% 48.6% 97.7% #DIV/0!

MHDU 192 - CRITICAL CARE 105.0% 93.3% 101.7% 103.3%

SDU 100 - GENERAL 102.2% #DIV/0! 93.3% #DIV/0! 21.9% 0.8% 7.7% 0.00 0.00NICU 420 - PAEDIATRICS 64.7% 52.2% 62.2% 54.4% 12.0% 2.6% 3.1% 5.80 1.92Swift 100 - GENERAL 68.7% 123.4% 50.8% 195.0% 24.2% 0.7% 0.0% 0.00 2.00

Cherry 300 - GENERAL 94.0% 103.3% 100.0% 101.7% 33.0% 0.3% 0.0% 0.00 0.59AMU 300 - GENERAL 86.7% 103.6% 99.4% 126.7% 18.6% 1.2% 5.7% 0.00 1.00

1.00

0.00

5.3%

8.1%

2.6% 6.4% 2.25

4.2% 3.1% 1.00

Appendix 3

Divisional Narrative

Medicine and Emergency Services

Safer Staffing is reviewed on shift by shift basis by the clinical Nurse Leaders of the Division.

Registered Nurses and Health Care Assistants are redeployed across the Division ensuring that

any risk is mitigated. None of the red shifts detailed in the table were left unrectified and in the

worst case the shift was left with an ‘Amber’ status.

AMU – 70% at green. Ambulatory Care has been staffed by a member of ED staff when staffing

has been low which enabled the ward to work within safe numbers along with the Ward Manager

coming out of her supervisory role.

Cedar – 31% at green. This is mainly due to the team working against an old template which will

be adjusted for the next report. The ward has only had 2 shifts where staffing was rag rated at

red and the Stroke Specialist Nurse worked on the ward supported by the Clinical Nurse Leader.

Holly 33% at green and Swift 62% at green. Elderly care wards do not attract locum staff in the

same way as others and as such they have more vacant shifts. The Clinical Nurse Leaders and

Clinical Practice Educators are supporting theses wards to bring the overseas new starters up to

a proficient level for independent working. There are no immediate concerns and the

development strategy in place is on target.

Maple – 41% on green. The ward is only filling shifts where necessary based on acuity. They

also had a period where beds were closed due to infection so staffing was stepped down.

Although shifts are rated as red they have not been adjusted on the template which would reflect

a compliance rate nearer to 75%.

Red rated shifts have all been due to unfilled vacancy mostly with advanced notice of greater

than 72 hours. Staffing is improving (for example AMU has reduced from 48% to 19% in the last

month) but the lead time for some of the new nurses from overseas is lengthy. UK recruitment is

not making an impact and we are relying on our overseas campaigns to produce more yield.

Changes to establishments based on our last acuity and dependency review has meant that the

ward staffing templates have been adjusted but there has been some delay in the electronic

spreadsheets being adjusted. Emergency activity is slowing after the winter and escalation areas

are now reducing which has meant that there are a higher number of Bank staff available to

work. The Division continues to support the Agency price cap where possible and will seek

alternatives before going to Agency for shifts.

Staffing shortages are not thought to attribute to the Serious Incidents for the Division during

April.

Theatres, Anaesthetics, Surgery and Critical Care

The green safer staffing score for ITU is only 43% - to mitigate the immediate risk bank and

agency nursing staff are being employed to cover the daily gaps. Successful recruitment has

taken place at home and overseas, we are currently waiting for experienced overseas ITU

nurses to commence employment.

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There is generally a long lead in time with RNs who are recruited overseas, Of the RNs

employed, Falcon are awaiting 3 RNs, Kingfisher 4 RNs and SAU 1 RN, lack of accommodation

is one issue. RNs recruited at home we are currently waiting for 2 RNs for Kingfisher and 1 RN

for SAU. Daily nursing shortages are covered by bank and agency.

SAU is showing 68% due to supporting Kingfisher and Falcon nursing staff to achieve their

competencies. Daily nursing shortages are covered by bank and agency.

The surgical ward nursing vacancies have reduced in number, however there is a shortage of

RNs who can take charge on Kingfisher and Falcon. SAU and Heron continue to support these

two wards by temporarily relocating an experienced trained nurse each to Kingfisher and Falcon,

which assists with the skill mix.

In the last 4 months 13 new RNs have commenced work across the surgical wards which has

proved a challenge to support large numbers of inexperienced RNs. To mitigate the risk senior

nurses from Heron and SAU have been identified to support Kingfisher and Falcon by working

bank shifts to work alongside the new starters and support the new RNs in achieving their

competencies and ensure that their practice is safe.

Kingfisher and Falcon ward managers are still unable to roster their quota of supervisory days

due to the lack of seniority on the wards and therefore work clinically included in the daily staffing

numbers. Senior staff from Heron and SAU are working alongside junior staff and bank and

agency staff are also booked as required to release time for the ward mangers to work in a

supervisory role.

Diagnostics, therapies, Trauma and Orthopaedic

Dickens Ward has had their Band 7 Ward Manager on long term sick throughout April and a

vacant Band 6 post which means the leadership team is reduced in this time

Swan Ward has had 18% RED rated safer staffing levels, 12% AMBER rated therefore 70%

GREEN rated levels. Dickens has had 27%RED rated shifts, 19% AMBER therefor 54%

GREEN. Due to long term sickness Swan has seen an increase in agency usage through April,

this has had an impact on continuity, quality and harm free care seeing an increase in falls

(without harm) & pressure ulcer damage.

Swan Ward remains with two Band 6 Sisters on maternity leave until August which means the

leadership team are reduced in this time. Vacancy rate on Swan for trained nurses remains

4.46wte. A further RN has resigned his post and will be leaving at the beginning of May.

Swan ward has Band 7 CPE on maternity leave until September which is impacting on training

and education and quality support.

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Sickness on both wards remain high for April, Dickens had 2 members of the team on long term

sick & Swan had 3 RNs on long term sick (greater than 4 weeks)

In mitigation to the above statements, please no the following actions:

Swan Ward and Dickens Ward cross cover shifts where safely possible.

CNL and Ward Manager are covering short term/last minute absence to assure safe levels of

staffing where possible.

Recruitment plans – adverts out where necessary, recruitment days attended, active recruitment

is ongoing. Staffing structure and establishment review remains under review for both ward

areas

MDT working/cross professional boundary working to enhance team approach and provide safe

levels of care. Ward staff meeting to be held in May to discuss concerns and agree a

management plan of actions to address any safety concerns.

Trial of new daily working commenced on Swan ward with nursing staff, daily ward visits by CNL

& weekly documentation audits carried by WM

Women’s Health and Paediatrics

Maternity

We have recently recruited 2 new band 7 midwifery team leaders to ensure two band 7s on

labour ward each shift for support around managing complex cases.

The examination of the new-born is now carried out by the midwifery team in over 80% of cases

which assists with patient flow and continuity but has stretched midwifery staff this month. The

service is finding that the caseload of women are becoming more complex and that staff are

needing a range of midwifery and nursing skills to maintain safe care.

Paediatrics

Ash ward continues to support establishment in paediatric ED successful recruitment of band 5

nurses are beginning to reduce vacancy factor.

SI on Ash Ward was a patient who locked herself in a bathroom and tried to self harm. Patient

was being 1:1 supervised by Bank HCA as RMN was on her break.

NICU

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April had a decline in babies requiring intensive care 1:1 nursing including 10 days with no ITU

babies. This therefore reduced the % of red this month for ITU to 0% .20% of shifts were Amber

and 80% green.

HDU 1:2 nursing was 0% red 4% Amber and 96% green

Special care 1:4 nursing improved to green in April due to flexibility of staff related to reduction in

ITU activity. The red shifts are nursery nurses availability in April who support special care

nursing

SI was an unexpected death of a patient with overwhelming sepsis, in January 2016, initially

investigated as a Stage 3. Following Coroners report and discussion with Patient safety manager

it will now be investigated as a SI.

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Appendix 4

Overview of Care Hours Per Patient Day (CHPPD)

Lord Carter’s report into operational productivity and performance in acute hospitals found thatbetter planning of staff resources was crucial to improving quality of care, staff productivity andfinancial control. The Carter team found there is not a consistent way to record and report staffdeployment. This meant Trusts could not measure and improve on staff productivity.

The report, Operational productivity and performance in English acute hospitals: Unwarrantedvariations, recommended that all Trusts start recording Care Hours Per Patient Day (CHPPD) –a single, consistent metric of nursing and healthcare support workers deployment on inpatientwards and units. This metric will enable Trusts to have the right staff in the right place at the righttime, delivering the right care for patients.

Since the 1st May, all Trusts have been reporting monthly CHPPD data to NHS Improvement.NHS Improvement have tested the CHPPD data collection method with 27 Trusts during April2016 and preliminary analysis shows the data is robust.

By collecting CHPPD data each month, NHS Improvement will be able to identify whereunwarranted variation is happening and identify what good looks like. This will ultimately lead tobetter quality of care for patients and better financial control for Trusts.

Further detailed information on Lord Carter’s report can be found here:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_productivity_A.pdf