Executive Board in Public: August 2015
Item Public
Subject:
Safe Staffing Level’s Update Report -Compliance with Hard Truths
Doc
Author:
Ben Chambers, Lead Nurse for Clinical Assurance
Purpose:
Discussion
Key Issues:

Trust wide Compliance with safe staffing levels July 2015:
 Registered Nurse Day hours – 11,432.5 planned, 13,091
worked representing 115% fill rate.
 Registered Nurse Night hours – 10,400.5 planned 10,482
worked representing101% fill rate.
 Care Support Worker Day hours – 22,940 planned, 26,877
worked representing 117% fill rate.
 Care Support Worker Night hours – 13,299 planned,
17,611 worked representing 132% fill rate.
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:
£1.2m has had to be identified to facilitate improved staffing levels on
the wards. Ongoing review of this investment with our commissioners
should be considered and agreed going forward for any deficits in
staffing establishment that may affect compliance with delivering safe
staffing levels
Diversity/Equality
Impact Assessment:
No Equality issues have come to light; the review has considered all
protected characteristics equally.
Recommendation to
Board:
The Board is asked to note the improvement in staffing levels and
the direction of travel.
24/7 Safe Staffing Levels – Monthly Update Report
1.0 Introduction
NHS England and the Care Quality Commission issued joint guidance to Trusts on the delivery
of the ‘Hard Truths’ commitments, associated with publishing staffing data regarding nursing
and care staff levels. We have embraced the Safe Staffing agenda and implemented a number
of initiatives such as our surge and escalation process to ensure we receive real time
intelligence from our front line staff, on how we are meeting safe staffing levels.
Each month the Trust reviews the hours worked by the Trust’s substantive staff and NHSP
against the hours planned for in our 24/7 services. We benchmark the staff levels worked
against the expected safe staffing levels worked for the average occupancy of the ward.
By using the average occupancy measure the safe staffing figures more accurately reflect the
staffing needs of the wards during the month. The average occupancy figures are calculated
from the average occupancy percentages submitted to NHS England each month for
consistency across the Trust reports.
2.0 Monthly Safe Staffing Compliance Update
As many wards were operating at near capacity, only 2 wards were affected by using the
average occupancy rate to determine the safe staffing level. These were Blake ward where
their full occupancy level is 19 people, who had on average 18 people and April Cottage where
the full capacity is 7 and had on average 2 people.
Using the data based on average occupancy, 3 wards did not meet the expected safe staffing
levels for RN cover on some shifts and 1 ward for some CSW night Shifts.
1) Wingfield ward, where their average occupancy was 20 people. This required then to
have 3 qualified members of staff on over the 24hr period and at times they had 2. On
occasions this was when there were 18 people or less and at other times when qualified
staff could not be booked. During these periods additional CSWs worked on the ward.
Although this meant on occasions the Ward did not meet the ratio of 1 RN per 9 people,
the overall ratio of no more than 5 people per member of staff was always met.
2) Hayworth House, although they did not meet their RN safe staffing levels on 6 nights,
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they have maintained the number of RNs on nights at the 7 month high of 90% for the
2nd consecutive month, but need significant recruitment of qualified staff to ensure the 2
RNs on each night and consistency across the 24hr period. When no RNs could be
booked, additional CSW support was added to ensure that the overall ratio of no more
than 5 people per member of staff was always met.
3) Fenby ward, although they have reduced their occupancy levels to 8 people, their safe
staffing levels have not reduced as their ratio of qualified staff to people is set at 1:3.
Each day shift, there were at least 2 RNs on duty, but for 12 days of the month a 3 RN
was unable to be booked. However during these shifts additional RN support was
typically available from either the ward manager or Matron of the unit, RN cover that is
not included in the safe staffing calculations. Fenby ward also used additional CSW
support to meet their overall safe staffing ratios of 2:3 staff: people.
4) Albert ward, the less than expected CSW use at nights resulted from anticipated use of
RNs at night that had been booked before a change of ratio was introduced towards the
end of the month. The ratio of 1 staff : 4 people was always maintained.
The fill rate for day shift, registered nurse (RN) hours was 115% an increase of 7%.
The fill rate for night shift RN hours was 101% (an increase of 3% from last month).
The fill rate for Care Support Workers (CSW) was in excess for both day and night cover with
fill rates of 117% & 132% respectively. These figures represent an 8% and 16% decrease in
fill rate respectively on the previous month’s figures reflecting increases made to some wards
number of CSW workers following review of their RN needs.
Typically for units where between 95 and 100% levels for RNs have been reported it is as a
result of short notice absenteeism or NHSP being unable to provide cover for the shift.
Although there is ongoing recruitment to increase the number of substantive registered nurses
on the wards, there remains a shortage of suitable applicants. Options for increasing the
number and quality of applicants as well as improving the retention of registered nurses for
inpatient services continue to be explored to delivery consistent quality staff and leadership.
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Key for charts: Red indicates <90%, blue indicates 90% – 110% and yellow indicates >110%.
2.1 Services for People with a Learning Disability Division
Due to the care needs of people using our Learning Disability Service our skill mix includes a
high proportion of care support workers to support with activities of daily living, as such our
care support staff planned number is much greater than those for registered nurses.
Table 1 – LD safe staffing data July 2015
Total
Ward Name
Bramdean
April Cottage
Oakwood
Ashmount & Derby
Larkfield
Day
Registered Nurse
Total
Total
Monthly Monthly
Planned
Actual
Hours
Hours
465.0
464
449.5
499
434.0
410
465.0
890
403.0
489
Night
Care Staff
Total
Total
Monthly Monthly
Planned
Actual
Hours
Hours
1,395.0
1,360
1,348.5
1,340
3,472.0
3,283
2,790.0
2,872
1,209.0
1,510
Registered Nurse
Total
Total
Monthly Monthly
Planned
Actual
Hours
Hours
325.5
326
341.0
347
310.0
313
310.0
359
310.0
333
Care Staff
Total
Total
Monthly Monthly
Planned Actual
Hours
Hours
651.0
654
682.0
684
930.0
930
930.0
942
310.0
304
Adjusted figures for average ward occupancy July 2015
% Registered % CSW % Registered % CSW
Day
Day
night
night
Bramdean
100%
97%
100%
100%
April Cottage
111%
99%
102%
100%
Oakwood
94%
95%
101%
100%
Ashmount & Derby
191%
103%
116%
101%
Larkfield
121%
125%
107%
98%
Brief summary by ward
1) Bramdean – Consistent appropriate staffing across the 24/7 period.
2) April Cottage – April cottage have continued to use additional RN time during some day
shifts to facilitate staff development. During July a number of people were supported by
staff in their longer term community placements to support them through this transition
period. Consequently the staffing requirements did not significantly decrease, though
NHSP usage did.
3) Oakwood – Consistent appropriate staffing levels.
4) Ashmount and Derby – Consistent good staffing levels – the increase in Ashmount and
Derby’s RN staff levels during the day is as a result of moving towards a staffing model
of 1 RN for each area during the day.
5) Larkfield – consistent, appropriate staffing levels.
Current Actions
Teams are organising their staffing to meet the needs of the service. Where there are ongoing
vacancies (including those not being recruited to due to planned reorganisation of services),
mid-term agreements with temporary staff are being arranged through NHSP to provide
consistent care including supporting in the NHSP development programme. Ashmount has
also had additional management support put in to support the improvements the service are
making.
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2.2 Mental Health and Social Care Division
Due to the high levels of dependency and the acuity of some of the people using our Acute
Mental Health Wards, there is a need for quick responsiveness and flexibility regarding
additional resource (for example when people are escorted off the ward or are placed on
enhanced observation). We work closely with our front line staff to ensure that any additional
demands on staff are escalated, to ensure prompt action is taken to provide the required
support.
Table 2 – WAA safe staffing data July 2015
Total
Ward Name
24 7 Wingfield
24 7 Blake
24 7 Clare
24 7 Anderson
24 7 Delius
24 7 Elgar
24 7 Fenby (PICU)
Day
Registered Nurse
Total
Total
Monthly Monthly
Planned
Actual
Hours
Hours
1,069.5
845
713.0
1,047
1,069.5
966
713.0
709
713.0
834
713.0
878
1,069.5
929
Night
Care Staff
Total
Total
Monthly Monthly
Planned
Actual
Hours
Hours
713.0
1,114
1,069.5
1,197
713.0
817
713.0
688
713.0
873
1,069.5
989
1,069.5
1,127
Registered Nurse
Total
Total
Monthly Monthly
Planned
Actual
Hours
Hours
1,069.5
789
713.0
698
713.0
717
713.0
726
713.0
707
713.0
679
1,069.5
1,011
Care Staff
Total
Total
Monthly Monthly
Planned Actual
Hours
Hours
713.0
1,140
1,069.5
1,060
713.0
727
356.5
360
356.5
558
356.5
412
1,069.5
1,026
Adjusted figures for average ward occupancy July 2015
% Registered % CSW % Registered % CSW
Day
Day
night
night
24 7 Wingfield
79%
156%
74%
160%
24 7 Blake
147%
112%
98%
99%
24 7 Clare
90%
115%
101%
102%
24 7 Anderson
99%
96%
102%
101%
24 7 Delius
117%
122%
99%
157%
24 7 Elgar
123%
92%
95%
116%
24 7 Fenby (PICU)
87%
105%
94%
96%
Brief summary by ward
1) Wingfield ward – low RN levels reported for both day and nights as the wards average
occupancy was 20 people, resulting in an expected safe staffing level of 3 RNs. Where
additional RNs could not be booked CSW support ensured that the overall staff to
people on the ward ratio of 1:4 was always maintained.
2) Blake ward – appropriate consistent cover, the reported additional use of RNs during
the day was accounted for when there were 17 people admitted to the ward.
3) Clare ward – appropriate consistent cover.
4) Anderson ward – appropriate consistent cover.
5) Delius ward – appropriate consistent cover. The increase in CSWs has been due to
acuity on the ward and additional RN usage during the day accounted for the starting of
a new manager and Band 6 nurse.
6) Elgar ward – appropriate consistent cover with an increase in RNs during the days
accounted for by the charge nurses having some time put aside to conduct managerial
duties. The new ward manager is now in post and the Band 6’s have returned to clinical
duties.
7) Fenby ward – Lower than expected RN levels on 12 days for the 8 people being
supported. On these day shifts, there were at least 2 RNs on duty, however during
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these shifts additional RN support was typically available from either the ward manager
or Matron of the unit. Fenby ward also used additional CSW support to meet their
overall safe staffing ratios of 2:3.
Current Actions
Work is currently underway planning the staff teams for the working age adult inpatient
services when the new wards at Farnham Road hospital (which will see 3 acute wards and the
PICU move to Guildford) become operational at the end of the year. Currently efforts to recruit
to vacancies continue alongside support for the NHSP development programme.
2.3 Older Peoples Mental Health Division
Due to the care needs of people using our older people’s services our skill mix includes a high
proportion of care support workers to support with activities of daily living. The ratio of RNs
per person was reviewed in July and extended from 1:9 to 1:10. The overall ration of staff per
person remained the same for each OP ward as previously.
Table 3 - OP safe staffing data July 2015
Total
Ward Name
Victoria
Albert
Hayworth House
Spenser Ward
Bluebell Ward
Primrose Ward
Day
Registered Nurse
Total
Total
Monthly Monthly
Planned
Actual
Hours
Hours
682.0
1,123
356.5
706
713.0
637
682.0
910
356.5
378
356.5
380
Night
Care Staff
Total
Total
Monthly Monthly
Planned
Actual
Hours
Hours
1,364.0
3,348
1,426.0
1,444
1,426.0
2,086
1,023.0
1,046
713.0
1,016
713.0
767
Registered Nurse
Total
Total
Monthly Monthly
Planned
Actual
Hours
Hours
682.0
725
341.0
734
713.0
642
682.0
674
341.0
360
341.0
344
Care Staff
Total
Total
Monthly Monthly
Planned Actual
Hours
Hours
1,023.0
3,250
1,364.0
1,129
1,069.5
2,024
682.0
705
682.0
1,107
341.0
600
Adjusted figures for average ward occupancy July 2015
Victoria
Albert
Hayworth House
Spenser Ward
Bluebell Ward
Primrose Ward
% Registered % CSW % Registered % CSW
Day
Day
night
night
165%
245%
106%
318%
198%
101%
215%
83%
89%
146%
90%
189%
133%
102%
99%
103%
106%
143%
106%
162%
107%
108%
101%
176%
Brief summary by ward
1) Victoria ward – Good cover across the 24/7 period. The above 100% RN use resulting
from the change from 1:9 to 1:10 people per RN.
2) Albert ward – The above 100% RN use resulting from the change from 1:9 to 1:10
people per RN. Reduced CSW use this month at night accounted for by RN staff
required due to acuity.
3) Hayworth House – There has been no reduction in the frequency of the safe staffing RN
levels being met at night (remaining at 90%) the highest compliance figure for Hayworth
house for over 7 months. On those nights when only 1 RN was on duty the overall staff
ratio to people on the ward were met with an additional CSWs. Consistency of nursing
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care at Hayworth is currently being met by using longer term contracts with NHSP
qualified staff while recruitment to substantive RN positions continues.
4) Spencer ward – good consistent cover across the shift types and effective management
of nursing resource in response to the varying needs across the week. Increased RN
use during the day resulting from rosters being produced before the changes to Ratios.
5) Bluebell ward – consistent appropriate cover across the 24/7 period with the
requirement of additional CSWs over the 24/7 period due to acuity.
6) Primrose ward – consistent cover across the 24/7 period with over expected staff fill
rates due to acuity. The levels of required supportive observation are reviewed daily.
Current Actions
The OPS senior management are currently working with the Quality directorate to review the
staffing needs of each ward to ensure the quality delivery of care. As a directorate regular
discussions are held regarding the high fill rates and use of NHSP staff (especially for CSW
staff). Reviews of people’s support needs are carried out daily and the teams continue to
participate in the monthly available staffing meetings which support teams in ensuring that the
rosters are managed optimally each month.
3.0 Display information about the nurses and care staff present on each ward.
We now have full compliance with the displaying of nursing numbers on the wards. Further
ongoing audit will be undertaken to ensure the process remains embedded. New boards
have been introduced onto Blake ward to as a pilot site reflecting safe staffing expectations
and levels as well as information about the safety improvement work currently underway.
4.0 Processes in place to enable staffing establishments to be met.
The Lead Nurse for Clinical Assurance coordinates the available staff programme which
reviews the quality of rosters to ensure that they are being managed optimally each month.
The review team analyse possible future breaches on planned rosters, which should identify
unforeseen low levels of staffing. This information is then compared with NHSP booking data
which will allow for the robust monitoring of quality. This process also allows us to check that
appropriate allowances have been made in establishments for planned and unplanned leave
and the supervisory role of the ward manager.
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5.0 Reasons for Gaps in Staffing fill rate
The rolling recruitment processes commenced in September 2014 is now helping some
wards to reach their full staffing levels reducing the amount of NHSP required. A significant
number of wards currently have a full requirement of CSWs but recruitment to RN positions
remains challenging in line with other Trusts nationally.
The Trust continues to work in
partnership with NHS professionals to provide consistency of care through longer term
contracts and the development programme. The Trust weekly operational review meeting
monitors progress against all staffing risks currently on the Trust Risk Register.
6.0 Impact on Key Quality Outcome Measures
For the month of July no direct correlation has been identified between fill rate and inability to
deliver on quality outcome measures. Recruitment and retention of staff will be fundamental
in maximising the quality benefits of having a consistent staff team. Through the safe staffing
programme, the Quality team is working to ensure there is enhanced effectiveness of the
staffing resource leading to improving quality and care on the wards.
Ben Chambers – Lead Nurse for Clinical Assurance
01st September 2015
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