Nursing & Midwifery Establishment
Review
December 2014
1.0 Introduction
1.1 Following the ‘Hard Truths’ publication and in line with the National Quality Board
recommendations ‘How to ensure the right people, with the right skills, are in the right
place at the right time - A guide to nursing, midwifery and care staffing capacity and
capability’, one of the expectations of this document is that a nurse staffing review will take
place twice yearly as a minimum. This is to ensure the Board receives assurance that patient
safety is being maintained in regard to staffing numbers and skills.
1.2 The report is also to provide an assurance both internally and externally, that ward
establishments are safe and that staff are able to provide appropriate levels of care to
patients and that level reflects the Trust values and the 6 Cs of the National Nursing Strategy
(2012). This is particularly important in light of key recommendations made in the Francis
Report (2013) and the Berwick Report (2013).
1.3 The report also supports Care Quality Commission requirements under the Essential
Standards of Quality & Safety, including outcomes 13 (staffing) and 14 (supporting staff).
2.0 Background
2.1 This is the third nursing establishment review following the publication of the Francis
report and its recommendations. The last was in July 2014 The Trust has a duty to ensure
that ward staffing levels are adequate and that patients are cared for safely by appropriately
qualified and experienced staff. This must be carried out twice a year in line with the
recommendations.
2.2 As outlined previously the evidence suggests that appropriate staffing levels and skill
mix influences patient outcomes and harms, for example:
•
Reducing failure to rescue
•
Reducing pressure ulcer incidence
•
Reducing adverse incidents, particularly related to medication errors and falls
•
Improves the patient experience
3.0 Summary of key recommendations and actions and implemented from the July 2014
nurse staffing establishment review:
3.1 The July 2014 review recommended to the Board in order to provide further assurance.
➢ Investment of 3.0 WTE Registered Nurses to the ‘pool’ for short notice cover, to
maintain patient safety may need pump priming or need to skill mix the existing
Nursing Assistants
➢ Ward 50 needs a further review in 3 months
➢ Ward 51(now 48) required more information/analysis
➢ Ruby Ward needs a comparative review with the peer rehabilitation wards as the
patient group is the same
3.2 Recruitment to the ‘pool’ has proved a challenge however a recent increase to the
Nurse bank RN numbers should support ‘last minute’ RN gaps on night duty.
Ward 50 has had a staffing review and short term measures were put in place for example
peaks in workload being supported by bank. This review will establish if further investment
may be needed. The Head of Nursing has supported a skill mix revision resulting in an
increase of the Band 6 post to two. This is to strengthen the senior nurse establishment.
Monitoring continues.
Ward 51 Monitoring of Ward 51 (now 48) has not identified a need for an increase of WTE
however it has been recognised there is a need to increase the Band 6 nurses by skill mix
revision – strengthening the senior nurse establishment similar to Ward 50.
Ruby Ward The ward has undergone a recent change in management. The Matron and new
Ward Manager are reviewing the nursing establishment together in terms of future need.
4.0 Methodology for 2014 establishment review
4.1 It must be remembered that the most important factor in any review is the professional
judgment of the senior nurses. Their view was then supported objectively by the use of the
following information:
Establishments were compared to July 2014
Patient Acuity using the Safer Nursing Care Tool (SNCT) as per national guidance
National standards for specialty wards e.g. Intensive Care
Review of Registered to unregistered ratios
Review of staff to bed ratios in line with national guidance
Utilisation of beds and bed occupancy
The nursing quality indicators and key safety and outcome measures were
used to inform the recommendations
• Role of the Supervisory Ward Manager
•
•
•
•
•
•
•
4.2 The review covered the general wards on sites as well as the Emergency Department
and Intensive Care Unit. It also covered Midwifery services
5.0 Establishments were compared to July 2014
5.1 Funded Increase of staffing has been agreed as well additional non funded posts have
been given to wards
6.0 Cover
Establishments have been agreed and have the following cover built in to the budget often
referred to or known as ‘headroom’
•
14.5% for annual leave (mid-range for A4C, built into establishment)
•
3.65% sickness (Trust target)
•
1.5% training (equates to 4 days per person)
7.0 Role of the Supervisory Ward Manager
7.1 One of the Francis Report (2013) recommendations was that Trusts should make all
ward managers supervisory, this means supplementary to the rostered workforce. Many of
the wards managers have been able to achieve this, however a small number are still
working towards this, as recruitment to vacancies although better, is still not complete to
achieve this 100% of the time. When gaps appear on the rota that cannot be supported by
bank or staff movement then it is expected that the ward manager will step into the gap.
This is seen as a NICE guidance ‘red flag’ and needs to be reported via Datix incident
reporting tool. Ward managers have been reminded to ensure a record is kept. Work is now
ongoing to ensure that the expectation of the role is clear. This is being supported by a
series of master classes.
7.2 In November 2014 NHS England published Safer Staffing: A guide to care contact time.
This document supports the work already done by the National Quality Board (NQB) and
NICE. The document outlines the need to study the nurses time even further looking at
direct care versus indirect care such as meetings, discharge planning etc.
7.3 Although the Trust has previously looked at the ‘Productive Ward and has also used
‘Lean’ techniques in the ‘Countess Way’ program the documents suggests that all Trusts
need to do a ‘Contact Time’ assessment to provide a baseline assessment indication of the
construction of care provided. This work is planned to take place in the first 6 months of the
year 15/16.This may help support the determination of the skill on wards as well as
reviewing non-clinical roles.
8.0 Acuity using the Safer Nursing Care Tool (SNCT) as per national guidance
8.1 As recommended by recent NICE guidance throughout October/November the Trust
undertook a review of patients’ acuity. This was carried out using the SNCT tool. As is the
case in a number of Trusts it is still apparent despite support from Matrons and IT, the use
of the scoring tool remains subjective. Therefore the information needs to be used with
caution and cannot be fully relied upon. It demonstrated many of the wards were not
applying the agreed acuity score in an objective way. Many of the patients scored the
highest dependency from admission through to discharge despite it being obvious that their
care needs had changed. Whilst in some case this may be true there were many instances
when patients were clearly less dependent at the point of discharge and often for a few
days prior to this. Going forward the automation of a dependency tool will built in to the
electronic care plans via Ameritech. This will be a project for the nursing team in partnership
with the IT team.
Following discussions with both Heads of Nursing, the Deputy Director of Nursing is meeting
with a number of Ward Managers and supported by the Practice Development Team to
ensure robust collection is carried out of a months’ worth of data to ensure this is objective
and accurate. This focused piece of work will ensure the acuity is being monitored and
validated. The participating Wards are 44, 45, 43 and 48 as they have been identified by the
Heads of Nursing as areas of challenge in relation to staffing levels and patient dependency
requiring further work.
9.0 National standards
9.1 There are no national mandated minimum standards for the general adult wards,
however recent NICE guidance made reference to- but stopped short of mandating – a 1:8
Registered Nurses to patient ratio on day shifts. The review does demonstrate that, in the
main, this is achieved with the current establishments on day shifts when there are no
staffing issues. The exception is on night duty on most of the general wards. The ratio for
night shift on these areas is 1:14 as a maximum. It was accepted in most hospitals that this
is the case however recent benchmarking has demonstrated that Trusts are moving to a skill
mix change on night duty for example where previously there had been 2 Registered Nurses
(RN) and 2 Nursing Assistants (NA) they have change to 3 RN/1 NA. This reflects the
increasing acuity of the patients. This will form part of the acuity review on the identified
wards above.
9.2 If the ratio was to be realised nearer the 1:8 ratio during the night shift then a further
investment of £320k would be needed to skill mix the current staffing on most general
wards form 2/2 to 3/1. This would achieve an RN patient ratio of 1:9.
9.3 Emergency Department staffing guidance has now been released in its draft format for
consultation. The Matron for the department is currently reviewing the draft
recommendations. Early indications demonstrate there may be a shortfall of Band 7 nurses
to perform the shift leader role and gaps in the compliance of a paediatric nurse on duty
24/7 although we do have access via the Children’s Unit. Further work is needed to
establish if there are enough current nursing hours to meet the minimum
recommendations.
The Deputy Director of Nursing is meeting the Lead Consultant and Matron to ensure that
the NICE Guidance’s ‘red flag’ guidelines are factored into the departmental dashboard.
Full guidance is not expected until May 2015 however it is not anticipated that there will be
much change to the draft. Once the document has been agreed the work will be completed
and the Board will be informed of the outcome.
10.0 Midwifery-This six month review demonstrates that the Midwifery staffing is currently
virtually in line with national recommendations with only a shortfall of 0.7WTE identified
from this review and a ratio of 1:29.8 which almost meets the national recommend ratio of
1:29.0.
In light of the pending NICE midwifery staffing guidance due for publication in February
2015 the Head of Midwifery will at this point take no further action regarding the 0.7 WTE
shortfalls against national recommendations & plans to benchmark Midwifery staffing
against the anticipated NICE guidance and take action if required
11.0 Paediatrics - Paediatrics are currently using paediatric patient acuity tool ‘System to
Escalate and Monitor’ (STEAM). The information will enable the Director of Nursing to make
an informed decision regarding staffing as the occupancy is at times low, the dependency of
the patients may be high . This work is not yet complete and will be reported back at the
next review.
12.0 Neonatal Unit - The Head of Nursing for Urgent Care is working in conjunction with the
Lead Nurse in Neonatal Unit, to review the establishment within the unit and determine if it
meets the requirements and dependency of the babies in their care. This work is likely to
take some months, however the unit does have a robust escalation process and utilises the
flexibility within its nursing teams at times of peak/demand. The work remains on-going in
NNU.
13.0 Adult Critical Care-The new adult Intensive Care Unit has seen progression towards full
achievement of the Core Nurse Staffing Standards for Intensive Care Units (Intensive Care
Society, 2013)

This year the Trust recognised the need to invest a further 125k Increasing the
Nursing establishment by a further 3.5wte Band 5
• Supernumerary shift coordinator is now ring fenced in the Registered Nurse
establishment.
• All senior Band 6 Registered Nurses hold a post registration qualification in Intensive
Care nursing; this is now being extended to the Band 5 Nurses.
14.0 Quality & Safety
The nursing quality indicators and key safety and outcome measures were used to inform
the recommendations
Much work has been done to improve the nurse sensitive indicators. These are referred to
as ‘red flags’. The most recent report for October/November 2014 detailed the following:
14.1 Safety Thermometer
This is a national tool for measuring hospital acquired harm - Pressure Ulcers, Falls, VTE
used by all acute Trusts and is a national CQUIN. It enables Trust benchmark and also
supports the information needed to identify any areas where staffing issues may contribute
to hospital acquired harm
The Trust has achieved the Safety Thermometer of greater that 95% harm free 6 times in 12
months. Of those- 5 have been in the last 6 months.
This demonstrates the Trust is decreasing the harms acquired. However the Trust has not
seen the sustainability. It does however remain above the national target.
14.2 Feedback -Real time Feedback via Hospicom
The response has never been high and November did see a dip in the negative responses-re
compassion and communication. It is difficult to draw any conclusion form this.
14.3 Staffing Incidents
The staffing incidents in respect of time of day demonstrate there are no trends with the
timings of the incidents logged - so no conclusions can be drawn from this. Staffing
incidents continue to be monitored closely with weekly and monthly review.
Staffing Incidents by Ward – Grouped by Time Band – November 2014:
Lack of Staff
No Time Indicated
Ward 33 Trinity Ward
Ward 42 Cathedral Ward
Acute Medical Unit
Ward 50 Newgate Ward
08:00 - 17:59
Ward 44 Bridge Ward
Acute Medical Unit
Ward 50 Newgate Ward
Ward 52 Castle Ward
Ward 54
18:00 - 23:59
Ward 42 Cathedral Ward
Acute Medical Unit
Ward 48 Northgate Ward
Ward 50 Newgate Ward
Totals:
Total
4
1
1
1
1
6
1
2
1
1
1
5
1
2
1
1
15
4
1
1
1
1
6
1
2
1
1
1
5
1
2
1
1
15
Monitoring Patient Harm
J;
I
November Staffing Incidents vs 'Red Flags'
14
12
10
8
6
4
2
0
Medication
Falls
Staffing
All November Incidents by Inpatient Ward and
Actual Harm
60
50
40
30
DEATH
20
SEVERE
10
MOD
0
LOW
NONE
14.4 Monitoring Patient Harm
The Acute Medical Unit (AMU) has seen the highest number of incidents logged. However,
the impact is none or low level. Ward 43 has recorded the highest number of moderates
primarily due to pressure ulcers. The planned acuity review will allow more in depth analysis
of dependency and will be able to determine whether the staffing accurately reflects the
dependency of patients. Robust monitoring of pressure ulcer prevention, detection and
management continues
15.0 Staffing planned vs actual
The Trust has been reporting its inpatient nurse and midwifery staffing on the NHS Choices
website as well as internally in wards. November has seen the Trust apply a rating -GRAPe it
is using its own agreed score this has been benchmarked with other Trusts and is
comparable with other organisations.
CODE
Percentage
Comment
Green
95-105
Safe
Red
90 and below
Needs close monitoring for
potential harm and escalation
Amber
90-95
Some observation required to
avoid further deterioration
Purple
105 or more
Exception
report
Red/Purple
Actions required if monthly
data averages Red/Purple
There has been an increase of purple days in a number of wards in November. This is when
additional staff are required and were in place over and above the ward establishments.
Examining in more detail this has been due to an increase of patients with dementia who
were at risk of harm. A number of these patients are Delayed Transfers of Care (DToC). This
is a growing challenge for the Trust and further work is taking place, supported by the
Dementia Team to develop a role in the Trust that can be accessed via the Nurse Bank in
order to provide/tailored one to one supervision when required.
The Deputy Director of Nursing is leading a review of the level of staff required to support
one to one supervision of patients. Alongside the Dementia Team there are plans to support
the recruitment and training of a generic ‘care and comfort’ assistant role to the bank. This
role has been very successful in the Planned Care Division. It is envisaged this role has the
potential to be ‘skilled up’ further to encompass diversion therapy. This would help support
the ever growing group of patients with challenging behaviour.
16.0 National warning indicators (red flags)
Nice issues guidance that Trust need to collect information of events that prompt an
immediate response by the registered nurse in charge of the ward. ‘Red Flags’
The response may include allocating additional nursing staff to the ward or other
appropriate responses. These are being monitored via datix reporting and are discussed at
bed meeting. Work is underway with the information team to enable the Trust to capture
any data without the burden of collection. Other indicators are Pressure Ulcers, falls, missed
breaks, nursing overtime and sickness. Trust as weekly should set other local ones as
needed
17.0 Results
The Deputy Director of Nursing has met with the Matrons of the inpatient general ward
areas and discussed their individual results with each of them. Valuing their professional
judgment is an important part of this review. In the main, the Ward Managers believe that
the staffing is sufficient to meet the needs of their patient group in the daytime shifts,
however a number are concerned about evening and night shifts. This increasing
dependency/acuity is trying to be met by the Nurse Bank. It is becoming an increasing
challenge to meet the demand and the use of bank and latterly agency is becoming a
dependency rather that a one off peak in workload. Further work will be undertaken to
explore how staffing resources can be utilized more effectively. The Trust is currently
working with a Department of Health Team (in conjunction with a piece of work with CoCH
finance team) in looking at workload efficiency. It is hoped this work will support ongoing
nursing and midwifery workforce reviews.
18.0 Recommendations
Staffing levels have improved across the Trust, however, despite a great deal of focus and
effort, the investment from the Board in 2013/14 has not yet reached its full effect due to
recruitment issues. Intensive recruitment has taken place locally, nationally and
internationally. As it stands in December 2014/January 2015 the vacancies still stand at
24wte RNs but the NA vacancies are minimal. In context this still puts the Trust in a better
position than most of its peers. Recruitment continues on a monthly basis. A focus is also
being placed on retention of staff with the inception of a Practice Development Team to
support preceptorship and ongoing support; this is becoming an asset to the nursing team.
18.1 The following areas of work are recommended to the Board in order to provide further
assurance

Task and finish project with Ward Managers reviewing how night shifts are
resourced

Detailed acuity on the identified wards then act on the outcomes

Review of the direct care versus indirect care as outlined in ‘A Guide to Care Contact
Time’

Monitor compliance of the ‘Nurse Staffing Escalation Policy’ through audit

Introduction of the care and comfort role on the staff bank

Built acuity into Meditech nurse care plans

Continue to monitor the staffing using GRAPe reporting.

Review of the bank nurse pay costs versus agency pay rates via Nursing & Midwifery
Workforce Transformation Group

To work on the introduction of e-rostering

Review ED staffing in line with NICE guidance when agreed

Review Maternity staffing in line with NICE Guidance once this is published

Monitor the impact of the implementation of the national RAG rating which will be
visible publically on NHS Choices
19.0 Conclusion and next steps
As outlined in the paper much has been done to ensure the staffing levels reflect the acuity
of the patient. Assurance has been provided from the indicators and methodologies used
that the level of staffing are in the main correct on the day shift hours with availability of
bank Nurses to cover peaks in demand. Level of harm is none or very low. However, more
detailed work is required regarding evening and night shifts to give full assurance. Currently
staff are utilised across the Trust following risk assessment during the night time hours.
The Board is asked to note the progress and recommendations made in this review in
respect of ongoing work to ensure that safe care is being delivered to our patients with the
right workforce.
Alison Kelly
Director of Nursing and Quality
January 2015