Trust Board (Public): December 2013
Item: /13 Public
Subject:
Safe Staffing Level’s Report
Author:
Jo Young, Director of Quality (Nurse Director)
Billy Hatifani, Director of Risk and Safety (Deputy DoN)
Purpose:
Discussion
Key Issues:




Some wards are not operating with the national average of 9.2
patient per nurse ratios (Blake, Wingfield, Victoria, Albert 1 and
Spenser and April Cottage)
This is made worse at night
The standard set to prevent compromising care is 5 patients per
registered nurse – which we are infrequently achieving
The residential care services and short break services staffing
appear reasonable as does that for Windmill House and CYPS
Health/Social
Impact:
Staff in hospitals where the staff levels are not deemed safe have
been known to have higher burnout rates and were approximately
twice as likely to be dissatisfied in their job. Good staffing levels will
lead to positive outcomes for people using our services
Financial
Implications:
Investment should be considered and has been estimated (without
enhancements) as:
 £840k in Working Age Adult Mental Health
 £610K in Older Person’s Mental Health
This will be offset in part by current temporary staffing spend
Diversity/Equality
Impact Assessment:
No Equality issues have come to light; the review has considered all
protected characteristics equally.
Recommendation to
the Board:
The Board is asked to support the recommended improvement in
staffing levels.
Surrey and Borders Partnership NHS Foundation Trust
24/7 Safe Staffing Report
Nurses and support Workers
1. Introduction
There is a growing body of research evidence which shows that nurse staffing levels make a
difference to patient outcomes (mortality and adverse events). Ensuring safe staffing levels
across the health service was a key recommendation of the Francis Report into failures at
Mid Staffordshire NHS Foundation Trust. In their response to the Francis Inquiry, the RCN
stated that they believed that unsafe staffing levels is one of the most important issues
facing the NHS, as a failure to tackle this would be to fail patients entirely. It was further
announced today (19.11.13) that hospitals will be expected to publish their staffing levels
monthly – commencing with acute general hospitals.
This is our first formal review of safe staffing levels since the publication of the Francis
Report. We are specifically looking at the numbers of nursing and support staff (excluding
other disciplines providing diversion or other activity in these services) in our 24/7 services.
The report looks at each Division and also attempts to benchmark our staffing levels to
available national averages.
Following the publication of the Francis Report there has been a move to look at producing
guidance around staffing levels, and a number of organisations – including NHS Scotland
who are doing this. NICE have been tasked to provide an evidence base for staffing levels
and it is anticipated that a guide for Mental Health Services will be available later in 2014.
Until then there is limited tools for us to use to benchmark our services, however, the RCN
publication on Safe Nurse Staffing Levels in the UK (2010) does provide an overview on
national average staffing numbers.
Staffing numbers provide a baseline for safety, but more sophisticated methodologies that
include consideration of skills mix, dependency, availability and deployment are all essential
to provide truly safe services. This requires joined up systems, good management attention
and a delivery focus in all leaders.
2. Compromising Care
The RCN Safe Nursing Staffing Levels in the UK (2010) offers a strong case with regards
not just getting the numbers of staff right on a ward but having the right number of qualified
staff on duty to prevent incidents. Figure one below shows how care is compromised by
short staffing by mean numbers of patients per registered nurse:
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Surrey and Borders Partnership NHS Foundation Trust
Figure 1: Care is compromised by short staffing by mean number of patients per RN
(NHS hospital wards)
Source: Ball and Pike, Employment Research/RCN 2009
In this study the average number of patients per registered nurse where the care is never
compromised is 5 patients to one registered nurse. This rapidly increases to care being
compromised every shift if you have 10 or more patients per Registered Nurse. This study
also concludes that insufficient administration time can also affect care.
The RCN Safe Nursing Staffing Levels in the UK (2010), indicates the average number of
patients to registered nurses in mental health services is 9.2 to a Registered Nurse. The
Royal College of Psychiatry indicated that they believe there should be 3 registered nurses
to 15 patients during the day (5:1) and 2 at night (7.5), regardless of how many other staff
are on duty.
We have tried to use these basic indicators when considering our safe staffing levels and
have prioritised the safe levels as follows:
A.
B.
C.
D.
Number of Patients per Registered Nurse (RN) (national average 9.2)
Consideration to compromised care study (5 patients to one RN)
Number of Patients per number of staff (national average 4.1)
Ratio of registered nurse to other staff (recommended 50:50)
3. Working Age Adults
There are 6 Acute Wards and 1 PICU across the Mental Health Division. Table 1 is a
breakdown of nurse staffing across each ward against the 2009 National Benchmarks as
highlighted in the Guidance on Safe Nurse Staffing Levels in the United Kingdom (2010).
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Surrey and Borders Partnership NHS Foundation Trust
Table 1: Working age adult mental health staffing numbers
Ward
Wingfield
Blake
Clare
Anderson
Delius
Elgar
Fenby (PICU)
Bed
Numbers
22
24
27
18
20
21
13
14
14
9
12
Number of
Number of Number of
Total
Number of
patients per
Total
patients per patients per
numbers of
patients per
all nursing
number of
RN
staff all nursing
Number of Number of Number of Number of nursing
RN
staff
staff
nursing staff
compared staff
RN on day RN on night CSW on CSW on staff
on
compared to
compared
on
duty
to
night compared to
time
time
day time night duty duty during
daytime
/
to National
during night
time
National
day time
national
Average of
shift
(national Average of
shift
mean = 9.2
4:1 night
mean 9.2) 4:1 daytime
time
3
3
3
2
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
4
4
2
3
2
2
2
2
3
3
2
3
4
1
2
2
1
1
1
2
2
6
7
7
4
5
5
4
4
4
5
5
4
5
6
3
4
4
3
3
3
4
4
7.33
8
9
9
10
7
6.5
7
7
4.5
6
11
12
13.5
9
10
10.5
6.5
7
7
4.5
6
3.67
3.43
3.86
4.50
4.00
4.20
3.25
3.50
3.50
1.80
2.40
5.50
4.80
4.50
6.00
5.00
5.25
4.33
4.67
4.67
2.25
3.00
RN to support
worker ratio day time compared to
national
average of
50:50
RN to
support
worker
ratio night time compared
to national
average of
50:50
50:50
43:57
43:57
50:50
40:60
60:40
50:50
50:50
50:50
40:60
50:50
50:50
40:60
40:60
66:33
50:50
50:50
66:33
66:33
66:33
50:50
40:60
*The National Benchmark for all other specialities is 61% Qualified. The RCN recommendation in their 2006 guidance was
65%Q/35%UQ
** From November 2013 the qualified to unqualified ratio on days is set to change to 60/40
Highlighted cells are the areas where, using the national averages, we are under resourced.
We should note also the columns signalled by the red arrow indicate we are significantly
under resourced if we were to try and meet the compromising care benchmark of 5 patients
per Registered Nurse in all services except Fenby when it has only 9 beds open. Our
daytime total patient to staffing numbers are reasonable, but less so at night. Together these
indicate our skills mix is probably not sufficiently rich enough to ensure safe staffing,
particularly in Wingfield, Blake and Clare at night, depending on the number of beds open.
Improvements can be made in the patient to staff numbers as indicated in red in Table 2
below:
Ward
Wingfield
Blake
Clare
Anderson
Delius
Elgar
Fenby (PICU)
Bed
Numbers
22
24
27
18
20
21
13
14
14
9
12
Number of
Number of Number of
Total
Number of
patients per
Total
patients per patients per
numbers of
patients per
all nursing
number of
RN
staff all nursing
Number of Number of Number of Number of nursing
RN
staff
staff
nursing staff
compared staff
RN on day RN on night CSW on CSW on staff
on
compared to
compared
on
duty
to
night compared to
time
time
day time night duty duty during
daytime
/
to National
during night
time
National
day time
national
Average of
shift
(national Average of
shift
mean = 9.2
4:1 night
mean 9.2) 4:1 daytime
time
3
3
3
2
3
3
2
2
2
2
2
3
3
3
2
3
3
2
2
2
2
2
3
4
4
3
3
3
2
2
2
3
3
3
3
4
3
2
3
2
2
2
2
2
6
7
7
5
6
6
4
4
4
5
5
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6
6
7
5
5
6
4
4
4
4
4
7.3
8.0
9.0
9.0
6.7
7.0
6.5
7.0
7.0
4.5
6.0
7.3
8.0
9.0
9.0
6.7
7.0
6.5
7.0
7.0
4.5
6.0
3.67
3.43
3.86
3.60
3.33
3.50
3.25
3.50
3.50
1.80
2.40
3.67
4.00
3.86
3.60
4.00
3.50
3.25
3.50
3.50
2.25
3.00
RN to support
worker ratio day time compared to
national
average of
50:50
RN to
support
worker
ratio night time compared
to national
average of
50:50
50:50
43:57
43:57
40:60
50:50
50:50
50:50
50:50
50:50
40:60
40:60
50:50
50:50
43:57
40:60
40:60
50:50
50:50
50:50
50:50
50:50
50:50
4
Surrey and Borders Partnership NHS Foundation Trust
The additional staff needed to achieve this would be:
Extra Numbers
Per Nurse on shift
WTE
Total (without
enhancements)
Registered
Nurse band 5
31750
6
13.44
£426,720.00
Support
Worker band 2
20,454
9
20.16
£412,352.64
£839,072.64
The total number of patients per registered nurses significantly improve and in all case meet
the national average and get closer or achieve the compromising care benchmark. This
recommendation assumes that the ward manager continues not to be included in the
numbers of registered staff on duty and predominately works 9-5 Monday to Friday.
Even with this skills mix profile the ratio of qualified to unqualified staff is not achieved in all
case, but improvement in registered nurse numbers would compensate for this. It should
also be remembered that this compliment of staff supports the assessment of people who
attend our place of safety S136 facilities.
The additional staff investment would be offset in part by reductions in temporary staffing.
a. Further Considerations
In addition to the findings the following areas highlighted in the RCN Guidance on Safe
staffing levels in the UK are thought to be apparent within our own Services and should be
considered in determining the appropriateness of the current staffing and skill mix:
A systematic review in 2007 concluded that there was evidence of an association between
increased Registered Nurse (RN) Staffing and a lower rate of hospital related mortality and
adverse patient events.
With the exception of Clare Ward we are currently working either within the lowest National
Benchmarks for Mental Health 50/50 or lower 40/60. The National Benchmark for all other
specialities is 61/39 and the 2006 RCN Guidance suggested a 65/35 skill mix.
To make judgements about numbers of staff needed requires insight into the roles and
competencies of different staff groups. As well as taking into account ‘who does what’
staffing levels will be effected by how things are done, in terms of the efficiency and
effectiveness of processes used.
Feedback from the inpatient clinical leads suggests that nurses are undertaking non nursing
duties. A piece of work is currently taking place to scope to what extent this may be
occurring, the findings will be shared within the working age adult mental health division.
The current and daily level of nursing staff is adequate to meet the needs of today’s patients,
and that the level of staff required, as identified through robust and regular reviews, is
maintained, even at times of financial pressure.
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Surrey and Borders Partnership NHS Foundation Trust
The following areas are considered to have either significantly increased or have been
introduced at ward level since the findings of the National Benchmarking of staffing ratios in
2009, and that this should be considered when determining the staffing needs of today.
Levels of Acuity and Dependency are thought to be increasing requiring more complex input
and interventions from staff. The recent Blake Review highlighted consistently high levels of
acuity and dependency. The identified clusters and reported incidents across inpatients
reflect similar presentations across each of our inpatient wards.
The ward clinical leads can exercise their clinical judgement on a shift by shift basis to
determine if staffing needs to increase as a result of increased clinical demand. However
the budgets have no flexibility to enable these increases to be funded. Resulting in what
were essentially minimum staffing establishments being funded as maximum
establishments.
There is thought to be an Increase in Direct Clinical Activity that takes nurses away from
either the ward environment or minimises opportunity for them to be available for other
clinical interventions i.e. S136’s, escorts, observations, ward rounds.
There is also thought to be an increase in indirect clinical activities that takes staff away from
people that use services i.e. audits, external regulators, visiting professionals, service review
and record keeping.
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Surrey and Borders Partnership NHS Foundation Trust
4. Older Age Adults 24/7 Inpatient Services
There are three wards providing assessment to people with mental health conditions, four
wards providing assessment for people with dementia and two wards providing continuing
care. Using the same national average benchmarks, table 3 sets out our current staffing
provision:
Table 3: Older people’s mental health staffing numbers
Ward
Total
numbers
of
Number
Number
Number
Number of
nursing
Bed
of RN on
of CSW
of RN on
CSW
on
staff on
Numbers
night
on night
day time
day time
duty
time
duty
during
day time
shift
Total
number
of
nursing
staff on
duty
during
night
shift
Number of
patients per
RN
staff
compared
to daytime /
national
mean = 9.2
Number of
patients
per
RN
staff
compared
to
night
time
(national
mean 9.2)
Number
of
patients per
all
nursing
staff
compared to
National
Average of 4:1
daytime
Number of
patients per
all nursing
staff
compared to
National
Average of
4:1
night
time
RN to support
RN to support
worker ratio worker ratio day time night time compared to
compared to
national
national average
average of
of 50:50
50:50
Victoria
(MH
assessment)
Albert 1
(Continuing
Care)
Hayworth
House
(Dementia
assessment)
22
2
1
3
3
5
4
11.00
22.00
4.40
5.50
40:60
25:75
15
1
1
3
2
4
3
15.00
15.00
3.75
5.00
25:75
33:66
18
2
1
4
3
6
4
9.00
18.00
3.00
4.50
33:66
25:75
Spenser Ward
(MH
assessment )
20
2
1
3
2
5
3
10.00
20.00
4.00
6.67
40:60
33:66
Bluebell Ward
1 (Dementia
assessment)
8
1
1
2
2
3
3
8.00
8.00
2.67
2.67
33:66
33:66
8
1
1
2
1
3
2
8.00
8.00
2.67
4.00
33:66
50:50
9
1
1
2
2
3
3
9.00
9.00
3.00
3.00
33:66
33:66
8
1
1
2
1
3
2
8.00
8.00
2.67
4.00
33:66
50:50
15
2
1
2
2
4
3
7.50
15.00
3.75
5.00
50:50
33:66
Bluebell Ward 2
(Dementia
assessment)
Primrose Ward
1
(MH
Assessment)
Primrose Ward
2
(MH
assessment)
Willows
(Continuing
Care)
Again the highlighted yellow cells indicate where we are not meeting the national average.
There are significant shortfalls in Victoria and Spenser Wards on both days but especially on
nights for numbers of patients per registered nurses. This is less concerning in the
continuing care wards (Albert 1 and Willows) where the patients are longer stay and their
care plans and predictability should generally be better known to substantive staff.
Generally during the day time the numbers of patient to staff member’s ratio is positive and
at night the wards operate more consistently above the national average. The ratio of
registered nurse to support staff dips to 25:75 in some services, but these are small staffing
numbers and to achieve 50:50 is likely to be an over rich compliment of staff.
The Primrose and Bluebell Wards each operate as one service and looking at their staffing
numbers in this mode provides an improved picture as shown in Table 4:
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Surrey and Borders Partnership NHS Foundation Trust
Ward
Total
numbers
of
Number
Number
Number
Number of
nursing
Bed
of RN on
of CSW
of RN on
CSW
on
staff on
Numbers
night
on night
day time
day time
duty
time
duty
during
day time
shift
Total
number
of
nursing
staff on
duty
during
night
shift
Number of
patients per
RN
staff
compared
to daytime /
national
mean = 9.2
Number of
patients
per
RN
staff
compared
to
night
time
(national
mean 9.2)
Number
of
patients per
all
nursing
staff
compared to
National
Average of 4:1
daytime
Number of
patients per
all nursing
staff
compared to
National
Average of
4:1
night
time
RN to support
RN to support
worker ratio worker ratio day time night time compared to
compared to
national
national average
average of
of 50:50
50:50
Bluebell Wards
(Dementia
assessment)
16
2
2
4
3
6
5
8
8
2.67
3.20
33:66
40:60
Primrose Ward
1
(MH
Assessment)
17
2
2
4
3
6
5
8.5
8.5
2.83
3.40
33:66
40:60
Improvements to the other services can be made in the patient to staff numbers as indicated
in red in Table 5 below:
Ward
Victoria
(MH
assessment)
Albert 1
(Continuing
Care)
Hayworth
House
(Dementia
assessment)
Total
numbers
of
Number
Number
Number
Number of
nursing
Bed
of RN on
of CSW
of RN on
CSW
on
staff on
Numbers
night
on night
day time
day time
duty
time
duty
during
day time
shift
Total
number
of
nursing
staff on
duty
during
night
shift
Number of
Number of
Number
of
Number of patients
patients per RN to support
patients per
RN to support
patients per per
RN
all nursing worker ratio all
nursing
worker ratio RN
staff staff
staff
day time staff
night time compared compared
compared to compared to
compared to
compared to
to daytime / to
night
National
national
National
national average
national
time
Average of average of
Average of 4:1
of 50:50
mean = 9.2 (national
4:1
night
50:50
daytime
mean 9.2)
time
22
3
2
3
3
6
5
7.33
11.00
3.67
4.40
50:50
40:60
15
2
1
3
3
5
4
7.50
15.00
3.00
3.75
40:60
25:75
18
2
2
4
3
6
5
9.00
9.00
3.00
3.60
33:66
40:60
Spenser Ward
(MH
assessment )
20
3
2
3
4
6
6
6.67
10.00
3.33
3.33
50:50
33:66
Bluebell Ward
1 (Dementia
assessment)
8
1
1
2
2
3
3
8.00
8.00
2.67
2.67
33:66
33:66
8
1
1
2
1
3
2
8.00
8.00
2.67
4.00
33:66
50:50
9
1
1
2
2
3
3
9.00
9.00
3.00
3.00
33:66
33:66
8
1
1
2
1
3
2
8.00
8.00
2.67
4.00
33:66
50:50
15
2
1
2
3
4
4
7.50
15.00
3.75
3.75
50:50
25:75
Bluebell Ward
2
(Dementia
assessment)
Primrose Ward
1
(MH
Assessment)
Primrose Ward
2
(MH
assessment)
Willows
(Continuing
Care)
This proposal would achieve staffing averages for daytime shifts but not all night shifts;
although for both day and night the ratio of patient to staffing numbers achieves national
average. The standard of 5 patients per registered nurse in not achieved, but the numbers of
registered nurses improve and get much closer to this standard. In addition the ratio of
numbers of patients per total staff numbers is well below the 4.1 average
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Surrey and Borders Partnership NHS Foundation Trust
The additional staff needed to achieve this would be:
Per
Nurse
Registered Nurse
band 5
Support Worker
band 2
Total Extra Numbers on
shift
WTE
Total (without
enhancements)
31750
6 13.44
£426,720.00
20,454
4
£183,267.84
£609,987.84
8.96
This recommendation assumes that the ward manager continues not to be included in the
numbers of registered staff on duty and predominately works 9-5 Monday to Friday.
Even with this skills mix profile the ratio of qualified to unqualified staff is not achieved in all
case, but improvement in registered nurse numbers would compensate for this.
The additional staff investment would be offset in part by reductions in temporary staffing.
a. Other considerations
Whilst current guidance would recommend a high percentage of RMN to HCSW it is
suggested the need to take into account the activity co-ordinators and the fact that OT
Physiotherapist and Music Therapist are also bringing skills to the unit which has an impact
on the quality of care. Equally all the Older People’s Mental Health Service (OPMH) wards
have functionalised the medical cover which again has an impact on the day to day running
of the ward. All the wards have a daily presence from either the consultant or the Staff
Grade.
Safe day-to-day staffing levels for older people’s wards should and are determined locally,
following principles that are set out in the 2010 RCN document, “Guidance on safe nurse
staffing levels in the UK” but with specific considerations relating to the nature of care for
older people with complex needs.
Due to the nature of some of the buildings where our services are provided, it is important
that ward managers are able to make timely decisions on safe staffing for their area and are
able to flex up staffing numbers according to need.
Current guidance talks about number of RN to HCSW but at SABP we have developed the
role of Assistant Practitioner within some of our wards, which has made a positive impact on
our skill mix within our wards. The Division has in post other support staff such as activity coordinators on all our organic assessment units and therapy support which again impact on
the quality of care delivered.
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Surrey and Borders Partnership NHS Foundation Trust
5.
Services for People with a Learning Disability
Determining the correct staffing levels has always been without any evidence based
guidance. What is the optimal local level and mix of nurses required to deliver quality care is
a perennial question. There is a growing body of research evidence which shows that nurse
staffing levels makes a difference to patient outcomes (mortality and adverse events). Most
of the evidence relates to hospital care and there is nothing specifically available in relation
to learning disability services.
Safe staffing levels for people who have learning disabilities services should be determined
locally but we also follow the principles set out in the RCN Safe Staffing Document 2010.
Nurses need to be supported to ensure safe and realistic day to day workload planning.
Additional support for 1:1 cover has been negotiated for some people who use services and
within services adjustments can be made to staffing levels in line with needs identified. The
needs of the people using the learning disabilities service are diverse from people with
profound multiple disabilities to those with challenging behaviour, autism or mental health
issues.
The degree of nursing input will be based on the individual’s care plan. Some of these
services are stand-alone services with no other support immediately available in an
emergency. Within some services the staffing duties will include meal preparation, domestic
duties, shopping etc.
There is a need to explore the issue of staffing levels further, the charts below show current
levels to which 24/7 services are working. Adjustments are made to include mid shifts in
some areas, as well as increasing or decreasing levels, based on needs and numbers.
We have reviewed the staffing levels in the following clusters: those with nursing (health
care assessment and treatment and registered care with nursing); residential care and short
breaks services. Table 6 below provides current services with nursing.
a. Services with Nursing
Using the national averages most of the services, with the exception of April Cottage, are
within the patient to registered nurse averages and Bramdean is within the compromising
care registered nurse number of 5 patients per registered nurse.
All services are within the patient per total staff ratio, and as expected the registered nurse
to support worker staff ratio is not 50:50 in most services – however this is usual for people
who have learning disabilities services.
Improvements could be made by considering if an additional registered nurse should be
included in day and night shift in April Cottage and reduce the numbers of support staff on
these shifts as seen in table 7 below.
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Table 6: Current staffing levels within services with nursing
Total
numbers
of
Number
Number
Number
Number
of
nursing
Bed
of RN on
of CSW
of RN on
CSW on day
staff on
Numbers
night
on night
day time
time
duty
time
duty
during
day time
shift
Ward
Bramdean
(A&T)
Total
number
of
nursing
staff on
duty
during
night
shift
Number of
patients
per
RN
staff
compared
to daytime
/ national
mean
=
9.2
Number
of
patients
per RN
staff
compare
d
to
night
time
(national
mean
9.2)
Number
of
patients
per
all
nursing
staff
compare
d
to
National
Average
of
4:1
daytime
Number
of
patients
per
all
nursing
staff
compare
d
to
National
Average
of
4:1
night
time
RN to
RN to
support
support
worker
worker
ratio ratio night
day time time compare
compare
d to
d to
national
national
average
average
of 50:50
of 50:50
7
2
1
4
4
6
5
3.5
7
1.17
1.40
33:66
20:80
7
10
1
1
1
1
3
3
1
1
4
4
2
2
7
10
7
10
1.75
2.50
3.50
5.00
25:75
25:75
50:50
50:50
Grandview
(A&T)
7
1
1
5
2
6
3
7
7
1.17
2.33
17:83
33:66
Holly
(A&T)
1
0
0
2
1
2
1
0
0
0.50
1.00
0
0
7
1
1
2
1
3
2
7
7
2.33
3.50
33:66
50:50
8
1
1
2
1
3
2
8
8
2.67
4.00
33:66
50:50
7
1
1
3
1
4
2
7
7
1.75
3.50
25:75
50:50
8
1
1
3
1
4
2
8
8
2.00
4.00
25:75
50:50
April Cottage
(A&T)
Tree
Ashmount
(Res with
nursing)
Derby
(Res
with nursing)
Larkfield (Res
with nursing)
Rosewood
(Res
with
nursing)
Table 7: April Cottage – flexing up beds
Number
Number Number
of
RN to
of
of
RN to
Total
Total
Number of
patients
support
patients patients
support
numbers number patients
per all
worker
per RN per all
worker
of
of
per
RN
nursing
ratio Number
Number
staff
nursing
ratio Number
Number of
nursing nursing staff
staff
night
Bed
of RN on
of CSW
compare staff
day time of RN on
CSW on day
staff on staff on compared
compare
time Numbers
night
on night
d
to compare
compare
day time
time
duty
duty
to daytime
d
to
compare
time
duty
night
d
to
d to
during during / national
National
d to
time
National
national
day time night
mean
=
Average
national
(national Average
average
shift
shift
9.2
of
4:1
average
mean
of
4:1
of 50:50
night
of 50:50
9.2)
daytime
time
Ward
April Cottage
(A&T)
10
2
2
2
1
4
3
5
5
2.50
3.33
50:50
66:33
Services for people with learning disabilities charge separately for each person above 7
places (national market) therefore are able to step up the nursing profile as needed. This
would be the expect staffing profile and this would achieve compliance with the national
average of patient to registered nurses and meet the compromising care benchmark of 5
patients per nurse.
No additional resource is needed as funding stream already identified.
b. Staffing Levels within Registered Care Homes
Each of these services employs two qualified nurses, one of whom would be the Band 7
Home Manager. They may cover from 9.00 – 17.00 hours, or shift as required. These
services employ Band 3 support staff who would undertake shift leader responsibilities. The
needs of the people who use services will determine if support is needed on a one to one
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Surrey and Borders Partnership NHS Foundation Trust
basis and over a 24/7 period. The Regulation and Quality Improvement Authority (June
2009) published guidance on staffing levels in residential care homes (based mostly on older
peoples care). They recommended:
During the Day:
 For up to 9 people:
 For 10 – 16 people:
2 staff (one in charge)
up to 4 staff (one in charge and 2-3 others)
During the night:
 For up to 9 people:
 For 10 – 16 people:
1 staff member
2 staff members (one waking and one on call)
Table 8 below demonstrates that our staffing levels are compliant with this recommendation.
Table 8: Residential Care Homes staffing numbers
SERVICE
Early
Late
Night
COURT HILL 10 Beds
3
3
HILLCROFT 10 Beds
3 Vacancies
3
3
1 waking
1 sleeping
2
REDSTONE 8 Beds
2 vacancies
2
3
1 waking
1 sleeping
SHIELINGS 10 Beds
No vacancies
4
4
2
c. Staffing levels for Short Term Breaks
Staffing levels for these services are based on occupancy. The model of care within these
services is the same as that within the Registered Homes, with shifts not always having a
qualified nurse on duty. When this occurs the shifts are run by Band 3 support staff.
SERVICE
Occupancy
Early
Late
Night
Total
KINGSCROFT 7/8
4
4
2
10
AND
5/6
3
3
2
8
JASMINE
Under 5
2
2
2
6
8 Beds
More work needs to be undertaken in relation to dependency levels. The introduction of the
Health Equality Framework (HEF) may assist with identifying individual needs and assist
with identifying the needs of individuals.
6. Drug and Alcohol 24/7 Inpatient Services Staffing Review
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Surrey and Borders Partnership NHS Foundation Trust
Windmill House is a 12 bed drug and alcohol detoxification and recovery unit based at St.
Peter’s Hospital, Chertsey. The unit offers stabilisation, detoxification and a four week
residential recovery programme including group and individual therapy.
All patients admitted need to be self-caring and all are voluntary i.e. not detained under the
mental health act. Patients are assessed as suitable by the referring clinician from the
referring community drug and alcohol team, and additionally assessed by a member of the
Windmill House clinical team, if necessary prior to admission to ensure there are no
complicating factors that would make detoxification on the Windmill House unit unsafe.
Where additional needs are identified, such as a physical disability, extra staffing is provided
to meet the needs of the patient.
At all times there are a minimum of 2 staff on duty at Windmill House, one of whom is always
a registered nurse. During normal working hours, 9am to 5pm, there are always multiple
staff on duty from a range of clinical backgrounds as they deliver the different aspects of the
therapeutic programme on the ward. From 5pm to 9am minimum staffing is maintained.
The level of staffing described above is considered appropriate for maintaining a safe clinical
environment for the delivery of routine clinical care. However, this does not account for
unpredictable circumstances when patient needs may change suddenly demanding a higher
level of staff attention at short notice. It is the policy of Windmill House that if the patient
deteriorates suddenly physically, they are assessed for transfer to an appropriate acute
medical unit, and it they deteriorate psychiatrically they are assessed for transfer to the
acute psychiatric unit.
7. Children and Young People’s 24/7 Services Staffing Review
Birchgrove is a five bed unit offering long and short term placements for children aged 5-18.
There are currently three young people placed at Birchgrove.
Staffing during the day varies between two and three depending on where the young people
are, and there are two members of staff on duty each night. A plan is in place to manage
staffing levels leading up to the closure of Birchgrove.
Conclusion
Centrally set mandatory staffing levels as supported by the RCN would be good for Mental
Health Trusts, as this will provide a level of consistency to our staffing decisions across our
24/7 wards and allow for wider national benchmarking of patient outcomes and
effectiveness. In order to deliver safe compassionate care in mental health and people who
have learning disabilities services, it is important that when deciding of the mandated levels,
due consideration is given to the acuity, dependency and risks that are managed by our staff
on a daily basis.
The UK Rafferty (2007) reported a 26% higher mortality for patients in hospitals that had the
highest patient: nurse ratios (in other words, poorer nurse staffing levels). Nurses in these
hospitals also showed higher burnout rates and were approximately twice as likely to be
dissatisfied in their job. We have many services that do not meet the preferred 5 patient per
nurse safest level indicated in this research.
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Surrey and Borders Partnership NHS Foundation Trust
Some wards do not always operate within staffing levels that are in line with national
averages, but a majority of our 24/7 wards especially in Older Adults appear to have a
sufficient patient to total staff in shift in the daytime compared to the benchmark. This is not
true on night duties.
A process that will allow the timely monitoring our staffing levels is currently being developed
and this should allow for prompt interventions to be instigated when staffing numbers are
deemed to be reaching levels of concern that do not promote safe compassionate care.
The Available Staff Programme is taking weekly reviews of Roster by Director of Quality,
Service Manager/ Matron, Associate Director of Quality and Service Improvement and HR
on a rotational basis across the month to ensure all services in each Division are reviewed.
The review will involve the use E-roster KPI’s to look at planned staffing and will use Roster
Perform to look at KPI’s going forward. The review team will analyse possible future
breaches on planned Rosters, which should identify any unforeseen low levels of staffing.
This information will then be compared with NHSP booking data which will allow for the
robust monitoring of quality and help control costs associated with emergency shift cover
through an agency.
Whilst this work will contribute to ensure effective deployment of current resources it will
not be able to address the fundamental shortfalls identified in this review.
8. Conclusions
Further to the Francis Report it is expected that national guidance on how to
calculate the necessary registered and other staff compliments to safely support the
dependency and risk of people are receiving services. It is likely that this will be
published later in 2014. Until such time we are required to publish six monthly our
safe staffing reviews.
Using the benchmarks for safe staffing and patient per nurse ratios we can find
shortfalls in our working age adult mental health services and our older people’s
mental health services. Our services for people who have learning disabilities need
to be mindful of nursing safety levels when flexing up beds.
The Executive Board discussed these proposals and whilst resourcing these
improvements was of concern, general support was given to address these
shortfalls. It was noted that regularly additional temporary staff are deployed to
enhance staffing levels therefore the improvements proposed will be in part offset by
reductions in temporary workforce.
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Surrey and Borders Partnership NHS Foundation Trust
9. Recommendations
The Board therefore are asked to support the recommendations to deliver safer
nursing staffing levels in all services using these benchmarks as the guide.
Jo Young. Director of Quality (Nurse Director)
Billy Hatifani. Director of Risk and Safety (Deputy DoN)
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