Safer Staffing Report
Agenda Item: 5b)
Board of Directors Meeting
Date: 25th June 2014
SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST
Monthly Shift by Shift Staffing Report
1.0
PURPOSE OF REPORT
The purpose of this report is to provide the Board of Directors with the monthly shift by shift
information required to be presented as part of the delivery of the Hard Truths commitments
associated with publishing staffing data regarding nursing, midwifery and care staff.
2.0
OVERVIEW
There are 5 expectations within the Hard Truths Commitments regarding the publishing of
staffing data, these are:
1. The Board receives a report every six months on staffing capacity and capability
which has involved the use of an evidence-based tool (where available), includes the
key points set out in National Quality Boar (NQB) report page 12 and reflects a
realistic expectation of the impact of staffing on a range of factors (first report by June
2014).
2. The Trust clearly displays information about the nurses, midwives and care staff
present and planned in each clinical setting on each shift. This should be visible, clear
and accurate, and it should include the full range of patient care support staff (HCA
and band 4 staff) available in the area during each shift. This was due by June 2014
and then each shift.
3. The Board receives an update containing details and summary of planned and actual
staffing on a shift-by-shift basis on a monthly basis, by June 2014.
4. The Trust will ensure that the published monthly update report specified in 3 above
[i.e. the Board paper on expected and actual staffing] is available to the public on the
Trust’s website and the relevant hospital(s) profiles on NHS Choices. This is due by
June 2014 and then monthly.
5. The Trust reviews the actual versus planned staffing on a shift by shift basis,
responds to address gaps or shortages where these are identified, uses systems and
processes such as e-rostering and escalation and contingency plans to make the
most of resources and optimise care on each shift.
The first expectation was achieved and presented to May Board of Directors. Staffing
information boards are in place across the Trust covering expectation 2.
This report covers expectations 3 – 5 to detail information and processes in place. The
monthly shift by shift staffing is also expected to be reported on a monthly basis via Unify
covering planned and actual staff on shifts covering all inpatient areas. It is also required for
the Unify data to be linked to NHS Choices website.
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Safer Staffing Report
Systems have been set up for every inpatient area to report their actual staffing to planned
staffing per shift to a centralised safer staffing email for the Clinical Governance and Quality
Directorate to collate, interrogate and identify any hot spots. This information has been
reviewed on a weekly basis via teleconference call with Lead Nurses and senior managers to
identify any hotspots from the previous week, any mitigations and actions taken to ensure
safe staffing, as well as discuss any concerns for the following week.
The information reported monthly via Unify and linked with NHS choices is ward by ward with
summaries of sites. This detailed information is attached within appendix 1. The graphs
below give an overview of the data and actual staffing within directorates with identified
hotspots of individual ward areas.
3.0
SHIFT-BY-SHIFT STAFFING ESTABLISHMENTS
The shift-by-shift reporting system in place in Beds and Luton Mental Health Services has
been replicated and implemented across all other inpatient areas. Following further
discussion with senior staff and review of the information returned this is being refined to
include establishment, planned and actual to ensure an accurate understanding of staffing
needs of each shift is considered. It is recognised that the systems locally and nationally are
still maturing. Where it is reported over 100% fill rates, this is due to additional staff required
to support increased observations. As the system for reporting is developed, the actual
against the planned will be more sensitive to ensure adjustment to reflect the requirements of
individual wards.
Information is received from each of the wards, collated and reviewed by Lead nurses and
Executive Directors, before final submission to Unify. It is expected that the Unify data will be
rag rated although it is not yet clear what the criteria for the rag ratings will be. It has been
proposed that this will occur following the first months data collection.
Bedfordshire and Luton
Essex
2
Safer Staffing Report
Learning Disability
Forensics and CAMHS
3
Safer Staffing Report
4.0
HOTSPOTS
The graphs above show that overall there are no hotspots for hospital sites, with cover across
the majority of areas being above 95%. The individual ward areas (in appendix 1) though do
highlight some hotspots as discussed below:
Crystal ward (58.1%) – The ward on a number of shifts has been covered with one
registered member of staff. Each shift is reviewed by the nurse in charge and matron and
staff are moved around the units as required to ensure safe staffing, but it is proposed for
2 registered staff on each shift. There have been no significant concerns in regards to the
safety and quality of care on the ward when reviewing clinical incidents and safeguarding
reports. This ward is on a site, where staff can be supported by staff from other wards, or
the site senior nurse if required.

Cedar House (106.0%) – This is a rehabilitation ward, and staffing requirements are
reviewed on a shift basis. There have been some shifts, where it was planned for 2
registered staff but were covered by a care support worker. There have been no
significant concerns in regards to the safety and quality of care on the ward when
reviewing clinical incidents and safeguarding reports.

Townsend Court (82.3%) – The ward on some shifts has been covered with one
registered member of staff. This has been reviewed by the matron with the nurse in
charge to review patient dependency and acuity and further support given with health
care support worker, although it is seen as best practice for 2 registered staff on each
shift. There have been no significant concerns in regards to the safety and quality of care
on the ward when reviewing clinical incidents and safeguarding reports.

Chaucer Ward (81.6%) – The ward on some shifts has been covered with one registered
member of staff. This has been reviewed by the matron with the nurse in charge to
review patient dependency and acuity and further support given with health care support
worker. This ward is on a site, where staff can be supported by staff from other wards if
required. There have been no significant concerns in regards to the safety and quality of
care on the ward when reviewing clinical incidents and safeguarding reports.

Woodlea (74.0%) - The ward on a number of shifts has been covered with one
registered staff rather than the planned, but at these times, the clinical unit manager has
based herself on the unit to work clinically. No concerns around safety or quality of care
have been reported or seen through clinical incidents and safeguarding reports

Maple ward (78.8%) - The ward on a number of shifts have been covered with one
registered member of staff, but on all these instances a band 4 member of staff has
supported the registered member of staff. There have been no significant concerns in
regards to the safety and quality of care on the ward when reviewing clinical incidents
and safeguarding reports. This ward is on a site, where staff can be supported by staff
from other wards if required.
Further comments
The appendix details the ward by ward staffing that has been submitted to Unify. It should be
noted, that these are for individual wards, and some areas are covered as a whole unit. An
example of this is within Learning Disability where Bronte Place, Keats House and Byron Court
are supported overall for registered nurses from Byron Court.
5.0
RECOMMENDATIONS
It is recommended that the Board of Directors:
1. Note the contents of this report
2. Identify any further work required to be taken forward.
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Safer Staffing Report
3. Approve report to be published on SEPT website and linked to NHS Choices
6.0
ACTION REQUIRED
The Board of Directors is asked to:
1. Approve report to be published on SEPT website and linked to NHS Choices
Report prepared by
Sarah Browne
Associate Director Clinical Governance and Quality
On behalf of
Andy Brogan
Executive Director of Clinical Governance and Quality
5
Safer Staffing Report
Day
Hospital Site Details
Site code *The Site
code is
automatically
populated when a
Site name is
selected
RWN10
RWN10
RWN10
RWN10
Ward name
Hospital Site name
ROCHFORD COMMUNITY HOSPITAL
ROCHFORD COMMUNITY HOSPITAL
ROCHFORD COMMUNITY HOSPITAL
ROCHFORD COMMUNITY HOSPITAL
RWN10
ROCHFORD COMMUNITY HOSPITAL
RWN10
RWN40
RWN40
RWN40
RWN40
RWN40
RWN50
RWN50
RWN65
RWN70
RWNH0
RWNH0
RWNH0
RWN20
RWN20
RWN20
RWN20
RWN20
RWN20
RWN20
RWN91
RWN92
RWNL3
RWNL8
RWNL8
RWNL8
Main 2 Specialties on each ward
ROCHFORD COMMUNITY HOSPITAL
MENTAL HEALTH UNIT (BASILDON)
MENTAL HEALTH UNIT (BASILDON)
MENTAL HEALTH UNIT (BASILDON)
MENTAL HEALTH UNIT (BASILDON)
MENTAL HEALTH UNIT (BASILDON)
THURROCK COMMUNITY HOSPITAL
THURROCK COMMUNITY HOSPITAL
Mountnessing Court
Churchview House
Heath Close
Heath Close
Heath Close
RUNWELL HOSPITAL
RUNWELL HOSPITAL
RUNWELL HOSPITAL
RUNWELL HOSPITAL
RUNWELL HOSPITAL
RUNWELL HOSPITAL
RUNWELL HOSPITAL
BIGGLESWADE HOSPITAL
ARCHER UNIT
OTHER COMMUNITY PREMISES
The Glades
The Glades
The Glades
Specialty 1
715 - OLD AGE
PSYCHIATRY
710 - ADULT MENTAL
Cedar/Willow Ward
ILLNESS
715 - OLD AGE
Clifton Lodge
PSYCHIATRY
715 - OLD AGE
Maple Ward
PSYCHIATRY
711- CHILD and
ADOLESCENT
Poplar Unit
PSYCHIATRY
715 - OLD AGE
Rawreth Court
PSYCHIATRY
710 - ADULT MENTAL
Assessment Unit
ILLNESS
715 - OLD AGE
Gloucester
PSYCHIATRY
710 - ADULT MENTAL
Grangewater Ward
ILLNESS
710 - ADULT MENTAL
Hadleigh PICU
ILLNESS
710 - ADULT MENTAL
Westley Ward
ILLNESS
715 - OLD AGE
Mayfield Unit
PSYCHIATRY
715 - OLD AGE
Meadowview Ward
PSYCHIATRY
715 - OLD AGE
Mountnessing
PSYCHIATRY
Churchview
314 - REHABILITATION
700- LEARNING
Byron Court (5 Heath Close)
DISABILITY
Bronte Place (4a Heath 700- LEARNING
Close)
DISABILITY
Keats House (2 Heath
700- LEARNING
Close)
DISABILITY
712 - FORENSIC
Alpine
PSYCHIATRY
712 - FORENSIC
Aurora
PSYCHIATRY
712 - FORENSIC
Causeway
PSYCHIATRY
712 - FORENSIC
Dune
PSYCHIATRY
712 - FORENSIC
Forest
PSYCHIATRY
712 - FORENSIC
Fuji
PSYCHIATRY
712 - FORENSIC
Lagoon Ward
PSYCHIATRY
Whitbread Ward
314 - REHABILITATION
Archer Unit
314 - REHABILITATION
Cumberledge Intermediate
314 - REHABILITATION
Care Centre
Beech Ward
The Coppice
Whichellos Wharf
Wood Lea Clinic
700- LEARNING
DISABILITY
314 - REHABILITATION
712 - FORENSIC
PSYCHIATRY
Specialty 2
Night
Registered
midwives/nurses
Total
Total
monthly
monthly
planned staff actual staff
hours
hours
Registered
midwives/nurses
Care Staff
Total
Total
monthly
monthly
planned staff actual staff
hours
hours
Total
Total
monthly
monthly
planned staff actual staff
hours
hours
Day
Night
Care Staff
Average fill
rate registered
Total
Total
nurses/midwiv
monthly
monthly
es (%)
planned staff actual staff
hours
hours
Average fill
rate - care
staff (%)
Average fill
rate registered
nurses/midwiv
es (%)
Average fill
rate - care
staff (%)
930
1035
1537.5
1515
320
330
650
650
111.3%
98.5%
103.1%
100.0%
997.5
1057.5
1500
1687.5
320
380
630
660
106.0%
112.5%
118.8%
104.8%
930
922.5
3577.5
3592.5
320
320
1670
1670
99.2%
100.4%
100.0%
100.0%
885
697.5
1732.5
2280
320
320
690
940
78.8%
131.6%
100.0%
136.2%
817.5
825
1882.5
2100
310
320
880
1280
100.9%
111.6%
103.2%
145.5%
937.5
772.5
3045
3180
320
320
1230
1270
82.4%
104.4%
100.0%
103.3%
930
847.5
1042.5
1230
620
620
700
770
91.1%
118.0%
100.0%
110.0%
952.5
922.5
1252.5
1267.5
310
310
620
610
96.9%
101.2%
100.0%
98.4%
982.5
967.5
975
1050
310
320
680
750
98.5%
107.7%
103.2%
110.3%
930
967.5
2572.5
3060
620
620
1500
1680
104.0%
119.0%
100.0%
112.0%
975
960
1252.5
1312.5
320
320
640
670
98.5%
104.8%
100.0%
104.7%
712.5
690
1912.5
1912.5
310
310
940
950
96.8%
100.0%
100.0%
101.1%
930
930
1650
1845
310
310
930
1060
100.0%
111.8%
100.0%
114.0%
892.5
885
1597.5
1620
610
610
630
640
99.2%
101.4%
100.0%
101.6%
495
495
907.5
885
310
310
310
310
100.0%
97.5%
100.0%
100.0%
465
540
1395
1440
310
310
620
760
116.1%
103.2%
100.0%
122.6%
142.5
157.5
787.5
697.5
0
10
310
300
110.5%
88.6%
#DIV/0!
96.8%
465
465
510
510
0
20
620
600
100.0%
100.0%
#DIV/0!
96.8%
930
922.5
930
960
620
610
620
600
99.2%
103.2%
98.4%
96.8%
465
555
930
802.5
310
310
310
310
119.4%
86.3%
100.0%
100.0%
930
877.5
1395
1402.5
310
310
930
1000
94.4%
100.5%
100.0%
107.5%
930
937.5
945
918.75
310
310
620
600
100.8%
97.2%
100.0%
96.8%
922.5
810
600
618.75
310
310
620
620
87.8%
103.1%
100.0%
100.0%
930
922.5
1830
1792.5
620
595
1240
1240
99.2%
98.0%
96.0%
100.0%
941.25
956.25
1867.5
1867.5
620
440
730
1100
101.6%
100.0%
71.0%
150.7%
465
930
465
915
495
1860
495
1927.5
325.5
651
325.5
640.5
325.5
651
325.5
651
100.0%
98.4%
100.0%
103.6%
100.0%
98.4%
100.0%
100.0%
795
787.5
1627.5
1642.5
294.5
294.5
589
589
99.1%
100.9%
100.0%
100.0%
517.5
540
1560
1537.5
333.25
333.25
376.25
376.25
104.3%
98.6%
100.0%
100.0%
465
517.5
892.5
810
290.625
290.625
290.625
290.625
111.3%
90.8%
100.0%
100.0%
765
566.25
1132.5
1282.5
310
310
620
630
74.0%
113.2%
100.0%
101.6%
6
Safer Staffing Report
RWNM3
RWNM4
RWNM4
RWNM5
RWNM5
RWNM7
RWNM7
RWNM7
RWNM8
RWNM5
RWNM5
RWNM5
RWNM8
RWNT1
RWNT1
RWNT1
RWNTH
105 London Road
Short Stay Medical Unit
105 London Road
Mayer Way
Townsend Court
Mayer Way
Luton & Central Bedfordshire Mental Health Unit
Luton & Central Bedfordshire Mental Health Unit
Coral Ward
Jade Ward
BEDFORD HOSPITAL SOUTH
Bedford MHAU
BEDFORD HOSPITAL SOUTH
Chaucer Ward
BEDFORD HOSPITAL SOUTH
Keats Ward
Fountains Court
Bedford Health Village
Luton & Central Bedfordshire Mental Health Unit
Onyx Ward
Luton & Central Bedfordshire Mental Health Unit
Robin Pinto Unit
Luton & Central Bedfordshire Mental Health Unit
Crystal Ward
ST MARGARET'S HOSPITAL
Cedar House
Beech Ward
Plane Ward
ST MARGARET'S HOSPITAL
Poplar Ward
Bedford Health Village
ST MARGARET'S HOSPITAL
SAFFRON WALDEN COMMUNITY HOSPITAL
Avocet Ward
314 - REHABILITATION
314 - REHABILITATION
715 - OLD AGE
PSYCHIATRY
710 - ADULT MENTAL
ILLNESS
710 - ADULT MENTAL
ILLNESS
710 - ADULT MENTAL
ILLNESS
715 - OLD AGE
PSYCHIATRY
710 - ADULT MENTAL
ILLNESS
715 - OLD AGE
PSYCHIATRY
710 - ADULT MENTAL
ILLNESS
712 - FORENSIC
PSYCHIATRY
715 - OLD AGE
PSYCHIATRY
314 - REHABILITATION
314 - REHABILITATION
314 - REHABILITATION
465
713
715 - OLD AGE
PSYCHIATRY
300 - GENERAL MEDICINE
300 - GENERAL MEDICINE 314 - REHABILITATION
502.5
713
472.5
1069.5
450
1058
290.625
713
290.625
713
290.625
713
290.625
713
108.1%
100.0%
95.2%
98.9%
100.0%
100.0%
100.0%
100.0%
930
765
1395
1710
290.63
290.63
871.88
1115.63
82.3%
122.6%
100.0%
128.0%
1395
1282.5
1860
2070
581.25
590.63
871.88
1106.25
91.9%
111.3%
101.6%
126.9%
795
697.5
930
915
290.625
290.625
290.625
281.25
87.7%
98.4%
100.0%
96.8%
465
472.5
465
502.5
290.625
300
290.625
300
101.6%
108.1%
103.2%
103.2%
855
697.5
997.5
1200
290.625
290.625
581.25
628.125
81.6%
120.3%
100.0%
108.1%
1065
1132.5
1380
1530
581.25
581.25
581.25
768.75
106.3%
110.9%
100.0%
132.3%
1162.5
1110
3532.5
3577.5
581.25
571.875
1678.125
1800
95.5%
101.3%
98.4%
107.3%
930
907.5
1395
1425
581.25
562.5
581.25
675
97.6%
102.2%
96.8%
116.1%
930
892.5
930
937.5
310
310
620
620
96.0%
100.8%
100.0%
100.0%
930
540
930
1545
290.625
300
581.25
731.25
58.1%
166.1%
103.2%
125.8%
690
930
930
577.5
900
945
930
1860
1860
1035
1552.5
1770
290.63
294.5
294.5
290.63
294.5
304
290.63
883.5
883.5
290.63
855
864.5
83.7%
96.8%
101.6%
111.3%
83.5%
95.2%
100.0%
100.0%
103.2%
100.0%
96.8%
97.8%
930
945
1860
1875
294.5
294.5
883.5
893
101.6%
100.8%
100.0%
101.1%
937.5
997.5
1387.5
1207.5
294.5
323
589
589
106.4%
87.0%
109.7%
100.0%
7