Trust Board Meeting
9 October 2014
Title of the paper:
Safe staffing – nursing and midwifery, bi-annual skills mix and month 3, 4
and 5 report
Agenda item:
334/21
Lead Executive:
Tracy Carter, Chief Nurse & Director for Infection Prevention and Control
Author:
Toni Nettleton, Lead Nurse Workforce
Trust objective:
Tick as appropriate:
Achieving continuous improvement in the quality of patient care that we
provide and the delivery of service performance across all areas;
Setting out our future clinical strategy through clinical leadership in
partnership and with whole system working;
Creating a clear and credible long term financial strategy.
Purpose:
To provide information and next steps following the establishment review of
adult inpatient wards and an update on progress regarding the arrangements
for managing safe nursing and midwifery staffing levels.
Previously discussed and date for further review:
Committee
Trust Leadership Executive Committee
Date
25 September 2014
PSQR
2 October 2014
Benefits to patients and patient safety implications
To assure we have sufficient qualified, skilled and experienced staff to meet patient care needs within
our adult inpatient wards to give good quality care.
Risk implications for the Trust
Patient safety and clinical care are likely to
suffer as a consequence of not having the right
staff with the right skills in the right place at the
right time.
Mitigating actions (controls)
Utilisation of bank and agency to maintain safe
staffing levels. Implementation of a real time
database and trust-wide shared access for senior
nurses to identify risks and manage nursing and
midwifery levels on a day to day basis.
Links to Board Assurance Framework, CQC outcomes, statutory requirements
The Care Quality Commission (CQC), under regulation10(3) of the Health and Social Care Act 2008
(Regulated activities) Regulation 2010
Legal implications
Financial implications
Recommendations
To approve the proposed changes.
To note month 3, 4 and 5 reports.
Agenda Item: 334/21
Trust Board – 09 October 2014
Safe staffing – nursing and midwifery, bi-annual skills mix
Presented by: Tracey Carter Chief Nurse and DIPC
1. Purpose
1.1 This paper presents the outcome of the establishment review of adult in-patient
wards to determine if the nurse staffing levels within in-patient adult wards have
sufficient qualified, skilled and experienced staff to meet patient care needs.
1.2 To provide an update regarding the arrangements for managing safe nursing and
midwifery staffing levels within the inpatient wards.
2. Background
2.1 Since the publication of the report from the Mid-Staffordshire NHS foundation
Trust public inquiry (2003), the review of increased Mortality rates in 14 trusts by
Bruce Keogh (2013) and Don Berwick’s review into patient safety (2013), risks to
patients were highlighted where organisations had not taken seriously when it had
been identified that the right people with the right skills at the right place and time
were not in place.
2.2 Collectively the National Quality Board, Chief Nursing Officer England along with
experts have now set out clear expectations of NHS providers and commissioners
through the paper ‘How to ensure the right people with the right skills, are in the right
place at the right time’ (2013).
2.3 The Care Quality Commission (CQC), under regulation 10(3) of the Health and
Social Care Act 2008 (Regulated Activities) Regulations 2010, ask that Trusts are
assured that there are sufficient numbers and mix of staff on duty to provide the best
and safest care to the people using the hospital. See appendix 1- 3 for Nursing and
Midwifery safe staffing papers for June July and August.
2.4 A previous review of adult inpatient areas was undertaken across West
Hertfordshire Hospital Trust (WHHT) in May 2013. The review utilised the following
tools and benchmarks:



Patient Dependency tool that benchmarks best practice wards in the UK
covering 28 clinical specialities by Keith Hurst - evidence based tool.
Professional Judgement and scrutiny to interpret results that takes into
account local context and patient needs including ward layout and design.
Best practice recommendations were utilised in areas where the patient
dependency tool was not specific e.g stroke units, high dependency units.


All results were triangulated and reflected the totality of Registered Nurses
and support staff.
Results were also benchmarked against the Royal College of Nursing (RCN)
minimum recommendation of 1:7 nurse to patient ratio and trained to
untrained skill mix. See appendix 4 for explanation of nurse to bed and staff to
bed ratios and current ratios within our adult in patient wards.
2.5 As recommended in the report from the Mid Staffordshire NHS Foundation Trust
Public Inquiry (2013) each ward has 37.5hrs of Band 7 acting in a supervisory
capacity to enable nurse leadership except in emergencies, as part of the nursing
provision on the ward.
2.6 Between June 23rd and July 11th 2014 the Chief Nurse led a further review of
adult ward based nursing establishments supported by the Lead Nurse for workforce
in partnership with the divisional heads of nursing. National Institute for Health and
Care Excellence (NICE 2014) recommend that several models are used when
undertaking establishment reviews to provide balanced assurance and the results
are triangulated. This review has also included the Safer Nursing Care Tool (SNCT)
which was not used in the previous establishment review. The NHS institute of
innovation and improvement deemed the SNCT not fit for purpose in 2013 but it has
now been revised and re-launched and deemed appropriate for use as an evidence
based tool. A summary of outputs can be found in appendix 5 and strengths and
limitations of tools utilised in appendix 6.
2.7 Following the establishment review NICE published its guidance for safe staffing
in adult inpatient wards in acute hospitals and made a number of recommendations
in relation to organisational strategy, principles for determining nurse staffing
requirements, setting the ward nursing staff establishments, monitoring and
evaluating ward nursing staff establishments. NICE also comment there is evidence
of increased risk of harm when a registered nurse is caring for more than 8 patients
during a day shift; this guidance was also considered within the review. NICE also
recommend each ward should determine the requirements for nursing staff to ensure
safe patient care and there is no single nursing staff to patient ratio that can be
applied across the whole range of wards.
3. Analysis/Discussion
3.1 The data sheets were reviewed by Lead Nurse for workforce with the Heads of
Nursing. The multipliers for SNCT (Appendix 7) and dependency benchmarks
(Appendix 8) were adjusted to reflect the 21.6% uplift applied at WHHT. An
assumption of 100% occupancy was incorporated into the analysis with any blanks
scoring zero as staff did not capture patients pending arrival to the ward following
discharges. Exclusions were also made for escalation areas (i.e Acute Stroke Unit
gym) and supervisory band 7 roles.
3.2 All band 7s and Matrons were consulted and proactively contributed to their
clinical areas under review as indicated in the NICE principals for determining and
setting ward establishments. The results were scrutinised and challenged by the
heads of nursing and the Chief Nurse.
Surgery and Gynaecology wards
3.3 The triangulated variance across Surgical and Gynaecology wards was -0.77wte.
This indicated that the Nursing establishment across surgery and Gynaecology is
currently safe. All wards that have a higher nurse to bed ratio at night have elective
capacity and were professionally judged as appropriate for the case mix.
3.4 It is recommended that the division review opportunities to move staff across
wards in response to the review outcomes.
Care of Older people wards and Dual Frailty Unit
3.5 The current SNCT is being revised for use within older people’s wards and we
are awaiting the outcome. The triangulated variances across the two care of older
peoples wards Sarratt and Croxley was 5.53wte.
3.6 These areas showed a significant variance in results in one of the models. The
dependency model is based on activities of daily living data that may not be reflective
of the real dependency of the patients in these wards. This is recognised as a
weakness of the tool. Further analysis will be undertaken in October 2014 to
reassess the acuity and dependency of our older people’s wards and consider
options to merge the nursing workforce across both wards to maximise efficiencies.
Both wards currently meet all the RCN safe staffing minimum recommendations to
deliver care to older people of 1:7 nurse to bed ratio, 50/50 skill mix and staff to bed
ratio of 3.2 – 3.8.
3.7 There is currently no guidance or benchmarks for staffing ratios or skill mix for the
new Dual Frailty Unit. The unit cares for older people with complex needs and has
been professionally judged to be suitably staffed to safely care for patients with
complex care needs.
General Medical wards
3.8 The triangulated variance for Winyard ward was 3.5wte and Red Suite 2.68wte.
These are both small 18 bedded wards. The current registered nurse to bed ratio on
days in both areas is 1:6 the staff to bed ratio is 1:4. On nights the nurse to bed ratio
is 1:6 on both wards, but the staff to bed ratio is 1:5 on Red Suite and 1:4 on Winyard
ward. Professional judgement has taken into account the size, layout and location of
these units within the main hospital and has deemed current levels of staffing
appropriate to maintain patient and staff safety day and night within these areas. The
current nurse and staff to bed ratios are in line with other acute medical wards within
the Trust.
Specialist medical wards
3.9 The triangulated variance across the medical specialty wards was 1.60wte, this
indicated the Nursing establishment is currently safe. Heronsgate ward in 2 models
indicates they require an increase to their current establishment however a regular
review of this area will continue to monitor fluctuations or changes to acuity and
dependency over time before any adjustment is made.
Acute Assessment Unit (AAU) Level 1
3.10 The AAU has a total of 45 beds, 18 of which are monitored and 9 are unsighted
cubicles away from the main clinical ward areas. The triangulated variance for AAU
L1 is 6.61wte. Whilst the model triangulation indicated that there is a variance of
between 1.87 and 2.49wte within each ward, professional judgement has taken into
account layout and design of the areas and has deemed current levels of staffing
appropriate to maintain patient safety day and night within the current bed
configuration.
3.11 As part of the unscheduled care work stream AAU level 1 will be changing its
focus to improve patient flow, pathways and efficiency. Within this project discussions
on the re-configuration of beds and the potential merger of clinical areas to maximise
flexibility and efficiencies within the current nursing workforce are taking place.
Acute Assessment Unit (AAU) Level 3 and Cardiac care unit (CCU)
3.12 The total triangulated variance for the three clinical areas within L3 of the AAU;
Green and Purple, Blue and Yellow was 17.87wte.
3.13 All areas in AAU level 3 were professionally judged to currently have the
appropriate level of staff in place to deliver safe care to patients due to the current
bed configuration including a 6 bedded isolation area, 12 cardiac monitored beds and
6 unsighted cubicles that are all away from the main bays of each ward. The CCU
has 11 monitored beds and a triangulated variance of 2.24wte.
3.14 A re- configuration of AAU Level 3 has been proposed that includes the
relocation of the CCU to AAU Level 3 with 24 monitored beds to reflect changes in
patient pathways, resulting in an improved patient experience. This change will
improve efficiency across the areas allowing a reduction of 5.67wte posts with a
predicted saving of £267,000 over 12 months (See appendix 9)
Aldenham Ward
3.12 Aldenham ward is comprised of 21 respiratory beds and a 6 bedded high
dependency unit (HDU). The triangulated variance was 4.22wte.The HDU is funded
to provide level 2 care for a designated cohort of patients, however the 3 week audit
indicated a reduced number of level 2 admissions than expected. As a result the
recommended establishment was less than the funded establishment.
3.13 Based on current acuity and dependency evidence it is proposed to reduce the
trained nursing planned hours by 11.5 a day (2.61wte trained nurses). It should be
noted that the acuity and dependency may not be reflective of the autumn, winter and
spring seasons within this respiratory ward and therefore the ward will be closely
monitored on a daily basis over the coming months.
3.14 If further reviews indicate that demand remains lower than anticipated, the Trust
should consider options for further reconfiguration of the bed base.
4. SUMMARY
4.1 The review utilised three tools to agree safe staffing levels. In light of the
strengths and weaknesses of the tools, professional judgement and scrutiny was
applied to provide a balanced assurance. The paper ‘How to ensure the right people
with the right skills are in the right place at the right time’ (2013) is clear that using
tools are only one approach to making decisions on staffing and that professional
judgement and scrutiny are critical when evaluating tool results to ensure decisions
are based on patient care needs and knowledge of the local context.
The overall triangulated variance from the three tools was 49.79wte. Based on acuity
and dependency outputs, proposed bed re-configurations and professional
judgement and scrutiny of the results a further 8.28wte were reduced from the initial
overall variance.
4.2 The summary of findings indicates that overall our clinical adult inpatient wards
have sufficient nursing staff on a shift by shift, day by day basis to safely care for
patients.
4.3 The nurse to patient ratio in all clinical areas is currently a minimum of 1:7 on
days and meets the minimum RCN recommendations.
4.4 At night the nurse to patient ratio is a minimum of 1:8 with the exception of 3
clinical wards within surgery whose nurse to patient range was between 1:9 and
1:10, theses areas have an elective case mix and were professionally judged as
appropriate.
4.5 The RCN recommends a 65/35 - 70/30 trained to untrained skill mix and 50/50 65/35 in older peoples wards. Of the twenty four clinical areas reviewed, eight fell
below this benchmark. This parameter however should not be looked at in isolation to
assess safe staffing but should be seen in conjunction with other parameters such as
the nurse and staff to bed ratios.
5. Next steps
5.1 As recommended a review of ward establishments should be undertaken on a
biannual basis as a minimum and presented to the Trust Board. Acuity and
dependency reviews should be carried out a minimum of 3 times a year to capture
seasonal variances.
5.2 To discuss the development of a daily acuity and dependency measurement tool
across our inpatient ward areas.
5.3 A profile of the experience and capability of the substantive workforce should be
undertaken to inform future reviews including vacancies, agency usage and staff
turnover.
5.4 Further opportunities to merge or re-configure should be considered for small
wards/units to optimise efficiency and flexibility of the nursing workforce.
5.5 Senior nurse coverage at Band 7 and 6 should be profiled and benchmarked to
achieve equity across all in patient clinical areas.
5.6 To carry out a detailed review of ward budgets to determine and agree the
distribution and recruitment of uplift required to support sickness, annual leave and
study leave. Some clinical areas are noted to have recruited to the full 21.6% budget
uplift which impacts on their ability to flexibly utilise the nursing workforce.
5.7 A full review and profile of unregistered clinical roles should be undertaken
across all clinical areas to inform and support the development of an unregistered
workforce strategy.
5.8 To continue the development of an integrated performance report that will be
owned by the ward managers and senior nursing divisional teams. The report will
include both quality and workforce metrics for example monthly data on falls,
pressure ulcers, test your care and I want great care, sickness/absence, and
vacancies. This will assist in measuring the safety and patient experience within our
wards and provide further ward to board assurance.
5.9 Review specials and escort use and investigate options for a pool to be
developed with specialist skills and reduce temporary usage.
5.10 Complete SNCT and dependency tools again in October 2014.
5.11 Review and present papers on Maternity and children’s skill mix and
establishments by December 2014.
6. Recommendations
6.1 The committee is asked to approve the proposed changes.
Tracey Carter Chief Nurse
15th September 2014
Appendix 1
Nursing and Midwifery Safe Staffing - month 3
1. Purpose
1.1 This paper provides an update on the progress regarding the arrangements
within the Trust for managing safe nursing and midwifery staffing levels within the
inpatient ward.
2. Background
2.1 It is now a national requirement for all hospitals to publish information about
staffing levels on wards, including the percentage of shifts meeting their agreed
staffing levels. This initiative is part of the NHS response to the Francis report which
called for greater openness and transparency in the health service.
2.2 A Nursing and Midwifery safe staffing paper was presented to the Trust Board in
July 2014 in response to the National Quality Board guidance in ensuring compliance
and commitment to the 10 expectations and recommendations, CQC compassion in
practice and recent National reports Mid Staffordshire Public Enquiry, Keogh and
Cavendish reviews and the Berwick safety report.
3. Analysis/Discussion
3.1 The Trust submitted all unify data to NHS England as required by the 10th July
2014 this will be available to view on NHS Choices website on or around the 24th July
allowing patients and the public to see how hospitals are performing.
See appendix 1 for June 2014 unify data by site and ward.
Overall the Trust saw a decrease in the percentage of filled hours against planned in
June. Over 33 wards/areas, this equated to 1,117 hrs unfilled hours for trained staff
and 254 hours for health care assistants on day shifts. On night shifts 414 hours
were unfilled for trained nurses/midwives against the planned hours required on duty,
for healthcare assistant 58 hours were on duty above planned hours.
All shifts day and night are professionally judged by the nurse in charge of the clinical
area for safety by RAG rating. Mitigations to maintain safe staffing were put in place
where risks were highlighted and concerns escalated in accordance with the Nursing
and Midwifery safe staffing escalation policy.
It is important to note that actual staffing levels submitted via the unify return
comprise all staff on duty including staff that were unplanned for trained and
healthcare assistants e.g 1:1 specials, escorts. This in turn would distort the actual
levels of staff required on duty to deliver safe patient care as these are essential staff
and would be above the required agreed planned hours.
The data therefore should not be looked at in isolation but be considered in line with
the shift RAG ratings exception report. See tables 1–3 below for the comparison data
and trends overall in the trust and then by hospital.
Table 1 – West Hertfordshire Hospitals overall percentage of filled against unplanned
hours
Average Fill Rate
West Herts Trust Overall
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
Trained Nurses/
Midwives Day
100.8%
97.9%
Trained Nurses/
Midwives Night
99.0%
99.1%
Health Care
Assistants Day
99.8%
99.0%
Health Care
Assistants Night
108.2%
100.3%
Target Fill Rate
100.0%
100.0%
July
August
Septemb
er
October
100.0%
100.0%
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Table 2 – St Albans City Hospital percentage of hours filled against unplanned
Average Fill Rate
St Albans City Hospital
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
Trained Nurses/
Midwives Day
106.5%
103.7%
Trained Nurses/
Midwives Night
97.5%
101.0%
Health Care
Assistants Day
98.2%
101.7%
Health Care
Assistants Night
100.0%
90.0%
Target Fill Rate
100.0%
100.0%
July
August
Septemb
er
October
100.0%
100.0%
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Table 3 – Watford General Hospital percentage of hours filled against planned
Average Fill Rate
Watford General Hospital
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
Trained Nurses/
Midwives Day
100.5%
97.7%
Trained Nurses/
Midwives Night
99.0%
99.0%
Health Care
Assistants Day
99.8%
98.9%
Health Care
Assistants Night
108.4%
100.5%
Target Fill Rate
100.0%
100.0%
July
August
Septembe
r
October
100.0%
100.0%
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Monthly comparison data and trends of the percentage of filled hours against
planned by division is shown in tables 4–6 below.
Table 4 - Medicine percentage of filled hours against planned
Average Fill Rate
Medicine
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
Trained Nurses/
Midwives Day
101.5%
97.7%
Trained Nurses/
Midwives Night
99.0%
98.7%
Health Care
Assistants Day
105.9%
104.4%
Health Care
Assistants Night
116.0%
107.1%
Target Fill Rate
100.0%
100.0%
July
August
Septemb
er
October
100.0%
100.0%
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Table 5 – Surgery percentage of hours filled hours against planned
Avergae Fill Rate
Surgery
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
Trained Nurses/
Midwives Day
101.6%
99.8%
Trained Nurses/
Midwives Night
97.1%
98.9%
Health Care
Assistants Day
102.9%
98.3%
Health Care
Assistants Night
127.2%
100.8%
Target Fill Rate
100.0%
100.0%
July
August
Septemb
er
October
100.0%
100.0%
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
Table 6 - Womens and Childrens percentage of filled hours against planned
Average Fill Rate
Womens & Childrens
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
Trained Nurses/
Midwives Day
98.7%
96.4%
Trained Nurses/
Midwives Night
100.2%
100.2%
Health Care
Assistants Day
75.6%
81.8%
Health Care
Assistants Night
79.7%
83.2%
Target Fill Rate
100.0%
100.0%
July
August
Septemb
er
October
100.0%
100.0%
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Some clinical areas are noted to have an increase in hours above planned for health
care assistants due to fluctuations in the acuity or dependency of patients on some
shifts e.g 1:1 specials, additional hours were required to maintain patient safety and
would be above the planned requirements of the daily staffing agreed.
3.2 Across all ward and departments there were 2,322 day and night shifts 2,215
shifts were rated green, 106 rated amber and 0 shifts were rated red in June 2014.
See appendix 2 for monthly detail by ward/department that incorporates areas not
included in the unify data reporting.
The trust overall saw an increase in amber RAG rates during the month of June.
Shifts rated amber rose by 2.6% from the previous month. See table 1 below.
Table 1 - West Hertfordshire Trust overall percentage shift RAG rating.
RAG Percentage
West Herts Trust Overall
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
May
June
Green
98.0%
95.4%
Amber
2.0%
4.6%
Red
0.0%
0.0%
100.0%
100.0%
Target RAG
July
August
Septembe
r
October
100.0%
100.0%
100.0%
100.0%
Novembe
December
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
All divisions reported an rise in amber rated shifts, 1% in medicine, 0.4% in surgery
and 8% in the division of women’s and children from the previous month, see tables
2-4 below for comparison data.
Table 2 - Medicine monthly percentage shift RAG rating
RAG Percentage
Medicine
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
May
June
Green
99.0%
98.0%
Amber
1.0%
2.0%
Red
0.0%
0.0%
100.0%
100.0%
Target RAG
July
August
Septembe
r
October
100.0%
100.0%
100.0%
100.0%
Novembe
December
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Table 3 - Surgery monthly percentage shift RAG rating
RAG Percentage
Surgery
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
May
June
Green
99.0%
98.6%
Amber
1.0%
1.4%
Red
0.0%
0.0%
100.0%
100.0%
Target RAG
July
August
Septembe
r
October
100.0%
100.0%
100.0%
100.0%
Novembe
December
r
100.0%
100.0%
Table 4 – Women and children’s monthly percentage shift RAG rating
RAG Percentage
Womens and Childrens
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
May
June
Green
95.0%
87.0%
Amber
5.0%
13.0%
Red
0.0%
0.0%
100.0%
100.0%
Target RAG
July
August
Septembe
r
October
100.0%
100.0%
100.0%
100.0%
Novembe
December
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
All areas who rated amber on a day or night shift took action to mitigate any risks to
maintain patient safety. Appendix 3 provides the detail for the safe staffing exception
report for June 2014, by division and ward, with mitigations to maintain safe staffing
on the amber rated days.
3.3 The establishment reviews for in-patient clinical areas and will be presented to
the trust board in September 2014.
4. Risks
4.1 Managing unexpected fluctuations in patient acuity and dependency both during
shifts and out of hours that require a higher level of staff than the agreed daily
requirement.
4.2 Surge areas that are opened in response to fluctuations in patient activity are at
risk of not having the appropriate safe staffing due to dependency on temporary staff.
4.3 Data is currently sourced from both electronic and manual data entry to enable
ratification of robust data collection. User error and administrative failure pose a risk
to accurate data gathering and assurance.
5. Recommendations
5.1 The committee is asked to:

Note the information and assurance

Note the ongoing work and actions
Jackie Ardley
Chief Nurse
16th July 2014
Appendix A
West Hertfordshire Hospitals Unify Fill rate indicator return Staffing: Nursing, midwifery and care staff June 2014
Day
Registered
midwives/nurses
Site
Code
Total monthly
planned staff
hours
Site
Name
St
Albans
City
RWG03 Hospital 1927
Watford
General
RWG02 Hospital 51432
Night
Care
Registered
Staff
midwives/nurses
Total
Total
Total
monthly monthly monthly
actual planned actual Total monthly
staff
staff
staff
planned staff
hours hours hours hours
1997.5
852.5
867
50245
25268.5 25000
Care
Staff
Day
Total
Total
Total
monthly monthly monthly Average fill rate actual planned actual registered
staff
staff
staff
nurses/midwives
hours hours hours (%)
1104
1115.5
44114
43688.5 17905.5 17997.5
West Hertfordshire Hospitals Unify Fill rate indicator return by ward
345
Night
Average Average fill rate fill rate - registered
care
nurses/midwives
staff (%) (%)
Average
fill rate care
staff (%)
103.7%
101.7% 101.0%
90.0%
97.7%
98.9%
100.5%
310.5
99.0%
Day
Hospital Site Details
Specialty 1
Total monthly Total monthly Total monthly
planned staff actual staff
planned staff
hours
hours
hours
Total monthly
Total monthly
planned staff
actual staff hours
hours
Total monthly Total monthly
actual staff
planned staff
hours
hours
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG03
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
St Albans City Hospital
- RWG03
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Watford General
Hospital - RWG02
Specialty 2
Care Staff
Day
Registered midwives/nurses
Ward name
Hospital Site name
Night
Main 2 Specialties on each ward
Registered midwives/nurses
Care Staff
Night
Average fill rate registered
nurses/midwives
Total monthly
actual staff hours (%)
Average fill rate care staff (%)
Average fill rate registered
nurses/midwives
(%)
Average fill
rate - care
staff (%)
AAU Blue Level 1
300 - GENERAL MEDICINE
1155
1147.5
690
667
1035
989
690
713
99.4%
96.7%
95.6%
103.3%
AAU Yellow Level 1
300 - GENERAL MEDICINE
1170
1181.5
690
793.5
1035
1035
690
759
101.0%
115.0%
100.0%
110.0%
AAU Green Level 1
300 - GENERAL MEDICINE
1177.5
1193
690
690
1035
1035
690
690
101.3%
100.0%
100.0%
100.0%
AAU Red Suite
300 - GENERAL MEDICINE
1192.5
1177.5
690
678.5
1035
1012
345
345
98.7%
98.3%
97.8%
100.0%
AAU Triage Level 1
300 - GENERAL MEDICINE
1968
1795.5
859
962.5
1035
1012
690
713
91.2%
112.0%
97.8%
103.3%
AAU Blue Level 3
300 - GENERAL MEDICINE
1440
1302
1035
1023.5
1380
1345.5
690
713
90.4%
98.9%
97.5%
103.3%
AAU Yellow Level 3
300 - GENERAL MEDICINE
1177.5
1128
690
632.5
1035
1000.5
345
356.5
95.8%
91.7%
96.7%
103.3%
AAU Green & Purple
Level 3
300 - GENERAL MEDICINE
1764
1737
1380
1276.5
1380
1357
690
667
98.5%
92.5%
98.3%
96.7%
Bluebell
430 - GERIATRIC MEDICINE
1537.5
1526
1380
1334
1380
1357
1380
1403
99.3%
96.7%
98.3%
101.7%
Winyard
430 - GERIATRIC MEDICINE
1192.5
1158.5
690
686
1035
954.5
690
667
97.1%
99.4%
92.2%
96.7%
Sarratt
430 - GERIATRIC MEDICINE
1882.5
1994
1380
1744
1725
1725
1035
1322.5
105.9%
126.4%
100.0%
127.8%
Croxley
430 - GERIATRIC MEDICINE
1537.5
1476
1035
1184.5
1380
1380
1035
851
96.0%
114.4%
100.0%
82.2%
Coronary Care Unit (CCU) 320 - CARDIOLOGY
1605
1515
241.5
230
1380
1380
0
0
94.4%
95.2%
100.0%
#DIV/0!
Cassio
300 - GENERAL MEDICINE
1192.5
1189
690
989
1035
1035
345
655.5
99.7%
143.3%
100.0%
190.0%
Gade
370 - MEDICAL ONCOLOGY
1192.5
1139.5
690
667
1035
1035
0
126.5
95.6%
96.7%
100.0%
#DIV/0!
Heronsgate
300 - GENERAL MEDICINE
1192.5
1216
782
705
1035
1035
345
345
102.0%
90.2%
100.0%
100.0%
Aldenham
300 - GENERAL MEDICINE
2227.5
2151
1035
1012
2070
2047
345
391
96.6%
97.8%
98.9%
113.3%
Acute Stroke Unit Watford 300 - GENERAL MEDICINE
2572.5
2515
1260
1337
2415
2415
1035
1104
97.8%
106.1%
100.0%
106.7%
De La Mare/Beckett
100 - GENERAL SURGERY
1927
1997.5
852.5
867
1104
1115.5
345
310.5
103.7%
101.7%
101.0%
90.0%
Letchmore
100 - GENERAL SURGERY
1192.5
1154
690
701.5
1035
1023.5
345
345
96.8%
101.7%
98.9%
100.0%
Ridge
100 - GENERAL SURGERY
1537.5
1542
1035
885.5
1035
1012
690
644
100.3%
85.6%
97.8%
93.3%
Flaunden
100 - GENERAL SURGERY
1537.5
1537.5
1035
1012
1380
1345.5
345
391
100.0%
97.8%
97.5%
113.3%
Cleves
100 - GENERAL SURGERY
1192.5
1153.5
1035
959.5
1035
989
345
437
96.7%
92.7%
95.6%
126.7%
Langley
100 - GENERAL SURGERY
1089
1058.5
448.5
570
690
667
345
333.5
97.2%
127.1%
96.7%
96.7%
5163.5
5163.5
333.5
345
5129
5129
333.5
310.5
100.0%
103.4%
100.0%
93.1%
1276.5
1290.5
345
295
1023.5
977.5
345
264.5
101.1%
85.5%
95.5%
76.7%
2116
2395.5
989
736
2081.5
2254
1012
828
113.2%
74.4%
108.3%
81.8%
Combined ITU
Starfish
SCBU
192 - CRITICAL CARE
MEDICINE
321 - PAEDIATRIC
CARDIOLOGY
321 - PAEDIATRIC
CARDIOLOGY
Elizabeth Ward
502 - GYNAECOLOGY
1537.5
1552.5
690
674
1035
1046.5
690
632.5
101.0%
97.7%
101.1%
91.7%
Delivery Suite
501 - OBSTETRICS
3487.5
3236
690
580
3105
3024.5
690
552
92.8%
84.1%
97.4%
80.0%
ABC
501 - OBSTETRICS
1260
1071
345
324
1035
1035
345
287.5
85.0%
93.9%
100.0%
83.3%
Victoria
501 - OBSTETRICS
915
757
345
306.5
690
655.5
345
287.5
82.7%
88.8%
95.0%
83.3%
Katherine
501 - OBSTETRICS
1605
1446.5
1035
699.5
1035
1035
690
563.5
90.1%
67.6%
100.0%
81.7%
Knutsford
501 - OBSTETRICS
345
345
345
299
345
345
345
299
100.0%
86.7%
100.0%
86.7%
Appendix B
Number of day and night shifts (includes long days early and late shifts) planned against actual on duty.
Please note the actual staff on duty would include staff unplanned but essential to maintain patient safety e.g. 1:1 specials and staff rostered and working clinically on a period
of supervision (orientation). These staff would be in addition to the planned staffing levels and distort the actual required staffing levels
No. of Day
Shifts
Division
Area
Planned
No. of Night
Shifts
Actual
Planned
No. of Day
Shifts
Actual
Planned
Registered Nurses/Midwives
Medicine
No. of Night
Shifts
Actual
Planned
Actual
Healthcare Assistants
AAU Blue Level 1
106
105
90
88
60
64
60
62
AAU Yellow Level 1
108
110
90
90
60
69
60
66
AAU Green Level 1
109
111
90
91
60
60
60
60
AAU Red Suite
111
115
90
90
60
59
30
30
AAU Triage
176
161
90
88
82
91
60
62
AAU Blue Level 3
127
127
120
119
90
89
60
62
AAU Yellow Level 3
109
113
90
86
60
56
30
31
AAU Green & Purple L3
160
178
120
120
120
118
60
58
Bluebell
141
151
120
119
120
129
120
123
Winyard
111
118
90
89
60
60
60
60
A&E
300
294
300
298
120
108
60
58
UCC Hemel
90
89
60
60
30
29
0
0
MIU SACH
60
60
0
0
0
0
0
0
Sarratt
171
190
150
150
150
156
90
115
Croxley
141
136
120
120
120
105
90
74
CCU
147
140
120
120
21
20
0
0
Cassio
111
110
90
90
60
86
30
57
Gade
111
107
90
90
60
58
0
11
Heronsgate
111
113
90
90
68
64
30
30
Aldenham
201
194
180
179
90
97
30
34
Acute Stroke Unit
231
231
210
211
90
126
90
96
2932
2953
2400
2388
1581
1644
1020
1089
Total
No. of Day
Shifts
Division
No. of Night
Shifts
No. of Day
Shifts
No. of Night
Shifts
Area
Planned
Actual
Planned
Actual
Planned
Registered Nurses/Midwives
Actual
Planned
Actual
Healthcare Assistants
Beckett
37
37
6
6
19
19
0
0
De La Mare
141
158
90
92
60
77
30
28
Letchmore
111
108
90
89
60
61
30
30
Flaunden
141
141
120
117
90
88
30
34
Ridge
141
151
90
88
90
77
60
56
Cleves
111
109
90
86
90
89
30
38
Langley
102
109
60
60
39
52
30
30
Combined ITU
449
449
446
446
29
30
29
27
Total
1233
1262
992
984
477
493
239
243
Starfish
111
116
89
85
30
29
30
23
CED
120
125
90
79
0
2
0
0
Safari Day Unit
42
70
0
0
16
16
0
0
Neonatal Unit
182
203
181
196
29
21
29
23
2
11
0
0
57
43
59
49
141
161
90
91
60
60
60
55
Delivery Suite
321
335
270
263
60
63
60
48
Alexandra BC
120
118
90
90
30
34
30
25
Victoria
90
87
60
58
30
33
30
26
Katherine
150
158
90
90
90
70
60
49
Knutsford
30
30
30
30
30
26
30
26
1309
1414
990
982
432
397
388
324
Surgery
Women's & Childrens
Paediatrics
Transitional Care Unit
Gynaecology
Maternity
Elizabeth
Total
Appendix C
June 2014 Trust safe staffing exception report
Nursing & Midwifery Professional Judgement safe staffing RAG Rates
Green - Staffing numbers are as expected on the rota and ward is assessed as being safely staffed taking into consideration workload and patient acuity. Staffing numbers are not as expected
but safe according to current workload.
Amber - Staffing numbers are not as expected and minor adjustments need to be made to bring staffing to a reasonable level given workload and acuity or staffing numbers are as expected
but given workload and acuity additional staff are required.
Red - Staffing levels inadequate to cope with current patient needs.
Division
Date
Shift
Professional
Judgement
Rag Rating
02/06/2014
Day
A
08/06/2014
Day
A
Trained nurse sent home due to sickness @10.00 .Both band 6 to work with each Hca.
09/06/2014
Day
A
Supervisory to be counted on numbers.
13/06/2014
Day
A
supervisory in numbers.
29/06/2014
Night
A
Had to move an RN to cath lab as open to 12 patient. Will be supported clinically by AAU L1 Blue, Yellow & Purple.
30/06/2014
Day
A
1 RN off sick. Supervisory in numbers.
02/06/2014
Day
A
Supervisory working in numbers. RN shift not covered.
14/06/2014
Day
A
1 csw shift for specialing is not covered.
30/06/2014
Day
A
supervisory working in numbers.
27/06/2014
Day
A
CSW to special has cancelled for long day. Have a CSW for night shift to special. Supervisory in numbers to support.
07/06/2014
Day
A
Short by one ENP day shift- however 2 x ANPs on duty.
08/06/2014
Night
A
14/06/2014
Day
A
Day ENP worked 07:15-17:00. No senior A&E doctor cover at night. Senior manager on-call (JA) advised that department have a night ENP service. Senior nurse on
shift ENPed.
17/06/2014
Day
A
2 senior nurses off sick , shifts out to NHSP, pulled 1 ENP as skill mix of concern. However the department is unsafe at present due to the skills required, remaining
staff very junior.Nurse redeployed to support. Lead nurse supporting.
UCC Hemel
20/06/2014
Day
A
Anp sent from AE
.
Acute
Stroke
Unit
25/06/2014
Day
A
1 staff phoned in sick, 1 staff carers leave 3 patients in the stoke gym shifts out to NHSP. Not filled.
30/06/2014
Day
A
2 RN's overseas nurses - With no PIN number supporting on LD.
14/06/2014
Day
A
1 RN short due to late sickness. Escalated to senior nurse. No spare staff available. NHSP shift times amended. Own staff contacted to see if they could cover.
Allocated to ensure that risk to patient safety minimised. Worked closely with Sarratt ward to ensure 1:8 ratio was maintained.
28/06/2014
Day
A
1 bank staff nurse LD cancelled, escalated to senior sister on call. Requested wit ammended start time. Moved staff from Sarratt to maintain patient safety.2
bank nurses on the night are substantive staff.
04/06/2014
Day
A
HCA short on long day. Supervisory in the numbers to support.
Area
AAU Blue
Level 1
Medicine
AAU Blue
Level 3
AAU Green
L1
AAU Red
Suite
AAU
Yellow
Level 1
Bluebell
A&E
Comments, Mitigation - Actions Taken to Ensure Safe Staffing Levels
Supervisory covering Early.
No ANP at night.
Croxley
Gade
Surgery
Day
A
LD short by one HCA. Senior Sister will cover AM shift
14/06/2014
Day
A
Sister on call informed no staff available
21/06/2014
Day
A
Moved staff to Heronsgate to cover there as they were short staffed.
27/06/2014
Day
A
we are 1 RN down. Shift was requested yesterday. Supervisory in numbers to support.
28/06/2014
Day
A
Bank nurse cancelled at the last minute. Bed manager informed no other staff available.
28/06/2014
Night
A
One R.N short for the night shift. Multiple patient moves made off the ward over night, further increasing the work load. Bed manager and Bleep holder made
aware at start of shift, additional staff requested however none available. Flaunden ward provided support with iv's
30/06/2014
Night
A
1 HCA not covered for LD, start time changed to 10.00hrs on NHSP system.
Senior Nurse did not arrive for night shift. Only two juniors on ward, Poor skill mix, plus increased work load. Bed managers + Bleep holders made aware. Senior
nurse from ward next door will help out.
02/06/2014
Day
A
Band 7 will cover as required.
05/06/2014
Night
A
Was covered but bank nurse off sick. Still trying to cover. Senior Sister is on call and can return if patient safety issue.
06/06/2014
Day
A
x1 night staff finishing at 07.00 so short for final hour. Starfish to support if required.
07/06/2014
Day
A
1 member of staff on a 1-6pm in the day. Senior sister on call will come in should any issue to patient safety arise. A&E aware of situation.
07/06/2014
Night
A
1 on night shift didn’t start till 9.30pm. Senior sister on call will come in should any issue to patient safety arise. A&E aware of situation.
10/06/2014
11/06/2014
Day
Day
A
A
Senior sister not supervisory
Will be covered by senior sister
14/06/2014
Night
A
Agency not filled. Staff on day worked 1400 -0230am to mitigate risk. A&E and Starfish aware, will support.
15/06/2014
Night
A
out to agency -not filled. Staff on MLD worked 1400 -0230am. A&E and Starfish aware, will support if required.
19/06/2014
30/06/2014
Day
Night
A
A
Will move nurses around ther service as required according to activity. Senior sister already clinical.
Night short after 04.30. A&E and Starfish aware, will support if required
01/06/2014
Day
A
total 14 babies on SCBU. Unit was safe as there were no admissions
12/06/2014
Day
A
15/06/2014
Night
A
2 students, 1 3rd year plus help from Safari.
shift out to agency who were unable to cover. Dependency of patients high. CED staff available and are able to assist if needed. Senior nurse on call and are aware
of the situation, available for advice by telephone where needed.
16/06/2014
Day
A
Supervisory band 7 avaliable to assist on ward. Patient dependency high. Shift out to agency
17/06/2014
Day
A
CSW shift out to agency. Band 7 avaliable to assist if needed
25/06/2014
Night
A
One trained member off staff short. Band 7 avaliable to assist if needed
Night= Increased activity+admissions overnight , agency nurse did not have skills suitable for the ward. CED aware and are able to assist if needed. Senior nurse on
call available.
07/06/2014
Day
A
Bank worker RGN cancelled shift long day. Currently have one pt who needs ITU bed but none available (patient to be monitored hourly). Also have a patient
booked for medical management today. Bed manager informed. No cover found. Staff split into 2 bays each and nurse in charge managed the medical
management and the ITU patient.
07/06/2014
Night
A
Currently have one pt who needs ITU bed but none available (patient to be monitored hourly). Also have a patient booked for medical management today. Bed
manager informed. No cover found. Staff split into 2 bays each and nurse in charge managed the medical management and the ITU patient.
13/06/2014
Day
A
Matron informed of staff shortage & would raise this at the meeting. No Supervisory to pull, no extra staff available to support. Request to Maternity for HCA for
this aftenoon - evening to support and shift times changed on NHSP to start at 1300hrs. There are no Electives today but there are 4 Gynae patients in AAU and 1
in ITU requiring repatriation. The ward is safe but busy.
14/06/2014
Night
A
Hca sick for night duty, bed managers informed & would send someone if they can
15/06/2014
Night
A
Short of 1 hca tonight, oncall senior nurse informed, shift out to bank. Not covered but Band 5's split ward into managable areas making the ward busy but safe.
Letchmore
CED
Womens & Childrens
05/06/2014
Neonatal
Unit
Starfish
Elizabeth
Delivery
Suite
ABC
Victoria
Katherine
21/06/2014
Night
A
1 Additional RGN booked for day shift for medical management. Short of 1 HCA at night. Shift out to NHSP & A5 completed and sent to Senior Nurse on call. Not
covered but staff on duty shared responsibility through having 2 bays each and doing all their own vital signs. Busy but safe.
24/06/2014
Day
A
Band 7 in numbers and not supervisory. Late cannot cover from own staff and NHSP not covered.
26/06/2014
Day
A
01/06/2014
Night
A
x1 RN supernumery can't work unsupervised. X6 elective patients to get in and no beds empty at present. Only 2 confirmed discharges. Band 6 co-ordinated the
shift and split the rest of the staff into 2 bays each with the assistance of the hca's. Band 7 on A/L
no HCA for triage or D/S, will deploy from other areas
02/06/2014
Day
A
Support shifts vacant requiring sharing between clinical areas.
02/06/2014
Night
A
Support shifts vacant requiring sharing between clinical areas.
05/06/2014
Day
A
HCA deployed from another clinical area for day shift , 1 shift remains unfilled, day and night. Staff moved between clinical areas affected to manager activity
depending on clinical demands.
05/06/2014
Night
A
1 shift remains unfilled night. Staff moved between clinical areas affected to manager activity depending on clinical demands.
06/06/2014
Night
A
short of HCA in night will have to redeploy from other areas
07/06/2014
Day
A
1 midwife DNA, agency contact, 1 redeployed to another area due to activity, therefore staff for maternity triage not available, triage re-deployed to delivery suite
whilst trying to arrange cover.
09/06/2014
Day
A
1 support staff shift unfilled, will require sharing between clinical areas or redeployment if shift remains unfilled on NHSP.
11/06/2014
Night
A
No HCA on D/Suite - shift out to NHSP. Agency midwife DNA on night shift. Shift put out again but not filled. Will have to move midwife from another area if
needed.
12/06/2014
Day
A
1 midwife down on DS, already out to NHSP. Redeployed staff within division to cover when needed.
17/06/2014
Day
A
1 midwife down on DS, already out to NHSP. Redeployed staff within division to cover when needed.
19/06/2014
Day
A
One Midwife moved from ABC to cover shortfall.
28/06/2014
Day
A
1 shift unfilled, support staff utilised, and local redeployment.
30/06/2014
Day
A
1 midwife cancelled 07.40 redeployment not possible due to current activity triage centralised on delivery suite ths may need to continue to mitigate for vacant
shift. 1 midwife DNA shift unfilled.
01/06/2014
Day
A
no HCA but will redeploy from another area
02/06/2014
Night
A
Support shifts vacant requiring sharing between clinical areas.
03/06/2014
04/06/2014
05/06/2014
05/06/2014
07/06/2014
11/06/2014
13/06/2014
15/06/2014
15/06/2014
28/06/2014
01/06/2014
04/06/2014
10/06/2014
16/06/2014
16/06/2014
02/06/2014
03/06/2014
Day
Night
Day
Night
Day
Day
Night
Day
Night
Day
Day
Night
Night
Day
Night
Night
Day
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
1 midwife early shift unfilled, supernumerary utilised to support
No support staff on nights. Will get HCA to help from another area if needed
Day and night. No HCA. Shift put out to NHSP. Midwife shift unfilled on NHSP. Support from other clinical area
Day and night. No HCA. Shift put out to NHSP. Midwife shift unfilled on NHSP. Support from other clinical area
1 midwife deployed from delivery suite due to activity, no support staff available.
No Midwife on late. Shift put out to NHSP. Support from other clinical area
No HCA on night. Shift put out to NHSP. Will have to get help from another area if not filled.
One midwive down on late shift. Shift out to bank but not filled. HCA from Victoria Ward to help.
No HCA on night shift. Shift out to bank but not filled. HCA from Victoria Ward to help.
1 shift unfilled activity managed within current staffing capacity.
no HCA support will redeploy from another area if required
No support staff on nights. Will get HCA to help from another area if needed
Will have to get HCA from ABC to cover Victoria Ward as well as ABC
HCA had to be redeployed to another area. HCA from ABC to help.
HCA had to be redeployed to another area. HCA from ABC to help.
No nursery nurse available, midwife will be required to under take these duties
1 long day uncovered supernumary to support this morning, vacant shift on NHSP.
03/06/2014
Night
A
1 shift vacant. Vacant shift on NHSP. Support provided from other clinical areas.
Day
A
05/06/2014
Day
A
Only 3 midwives on day shift, vacancy put out to NHSP. Midwife sent from DS to help with discharges. 4th midwife obtained for late shift to bring up to full
complement of staff.
Day - No HCA or nursery nurse. No shift put out to NHSP
06/06/2014
Night
A
short of HCA on shift will redeploy from other areas, have SN staff to assist, no nursery nurse available on night shift.
07/06/2014
09/06/2014
Day
Day
A
A
No support staff for early shift, shift remained unfilled NHSP. Staff shared Katherine and Knutsford.
support shift unfilled will require sharing between Katherine and Knutsford
11/06/2014
Day
A
Only 1 HCA . Will have to get HCA from other area to help. No breast feeding support workers.
11/06/2014
Night
A
Only 1 HCA . Will have to get HCA from other area to help. No breast feeding support workers. Only HCA on night shift
12/06/2014
Day
A
1 midwife down on DS, already out to NHSP. Redeployed staff within division to cover when needed.
13/06/2014
14/06/2014
15/06/2014
15/06/2014
30/06/2014
03/06/2014
06/06/2014
Night
Day
Day
Night
Day
Night
Day
A
A
A
A
A
A
A
No HCA on night. Shift put out to NHSP. Will have to get help from another area if not filled.
2 support staff shift unfilled, will require sharing between clinical areas or redeployment if shift remains unfilled on NHSP.
Midwife DNA'd for late shift. Shift on system but midwife not informed to work. Midwife came in and worked for 3 hours
Short of HCA's, will reploy within divsion to help support.
1 midwife not yet arrived for duty, shift remained unfilled due to failure of temporary staff arriving for duty. Ward manager utilised to cover .
No support staff, staff will be shared between Katherine and Knutsford
HCA shift vacant on day, shared responsibility Knutsford and Katherine.one of 3 shortages of HCA's will redeploy.
06/06/2014
Night
A
HCA shift vacant on night, shared responsibility Knutsford and Katherine.one of 3 shortages of HCA's will redeploy.
07/06/2014
10/06/2014
12/06/2014
Day
Night
Day
A
A
A
support staff shared between clinical area Katherine and Knutsford
No HCA but no patients at start of shift. HCA from Katherine ward to help if needed
1 midwife down on DS, already out to NHSP. Redeployed staff within division to cover when needed.
04/06/2014
Knutsford
Appendix 2
Nursing and Midwifery Safe Staffing - Month 4
1. Purpose
1.1 This paper provides an update on the progress regarding the arrangements within the
Trust for managing safe nursing and midwifery staffing levels within the inpatient wards.
2. Background
2.1 It is a national requirement for all hospitals to publish information about staffing levels on
wards, including the percentage of shifts meeting their agreed staffing levels. This paper will
be reported monthly.
2.2 The Trust submitted all unify data to NHS England as required by the 11th August 2014
this will be available to view on NHS Choices website on or around the 24th August allowing
patients and the public to see how hospitals are performing.
See Appendix 1 for July 2014 unify data by site and ward.
3. Analysis/Discussion
3.1 There has been discussion nationally that the breakdown of staffing data shown on NHS
Choices does not distinguish between qualified and unqualified staff. This is seen as
confusing for patients however as a Trust we do distinguish this in our reporting and the
Board papers are then displayed for the public on our safe staffing page on the internet site.
3.2 On 1 July 2014 the National Institute for Health and Care Excellence (NICE 2014)
published their guidance in relation to safer staffing and made a number of
recommendations in relation to the following:




Organisational strategy
Principles for determining nurse staffing requirements
Setting the ward nursing staff establishments
Assessing if nursing staff available on the day meets the patients nursing
needs
 Monitoring and evaluating ward nursing staff establishments
3.3 The recommendation from NICE that wards implement systems to report and monitor
nursing ‘Red Flags’ has attracted much debate in the press. The guidance points to a
number of patient factors that would denote a Red Flag event as well as quantifying a Red
Flag in terms of staffing levels. The guidance recommends the following as constituting a
Red Flag:



Less than 2 registered nurses present on a ward during any shift.
A shortfall of more than 8 hours or 25% (whichever is reached first) of registered
nurse time available compared with the actual requirement for the shift. For
example, if a shift requires 40 hours of registered nurse time, a red flag event
would occur if less than 32 hours of registered nurse time is available for that
shift. If a shift requires 15 hours of registered nurse time, a red flag event would
occur if 11 hours or less of registered nurse time is available for that shift (which
is the loss of more than 25% of the required registered nurse time.
Organisations to agree their own red flag events locally
In response to the NICE Guidance, a gap analysis will be undertaken in September with
senior nurses to benchmarking current practice against the recommendations. In particular
we will be working with national leads to better understand the application of the Red Flag
system and reconciling the percentages outlined above with the fill rates included in West
Hertfordshire Hospitals Trust Safer Staffing submission. The outcome and action plan will be
presented at the Trust Board in November 2014.
3.4 In July the Trust reported 1,094 unfilled hours for trained nurses and midwives and 841
hours above planned for health care assistants on day shifts. On night shifts 552 hours were
unfilled for trained nurses/midwives against the planned hours required on duty, for
healthcare assistant 839.5 hours were on duty above planned hours. Some clinical areas are
noted to have an increase in hours above planned for health care assistants due to
fluctuations in the acuity or dependency of patients on some shifts e.g 1:1 specials and
escorts.
3.5 All shifts day and night are professionally judged for clinical safety and escalated in
accordance with the Nursing and Midwifery safe staffing escalation policy.
3.6 It is important to note that actual staffing levels submitted via the unify return comprise all
staff on duty including staff that were unplanned for trained and healthcare assistants e.g 1:1
specials, escorts. This in turn would distort the actual levels of staff required on duty to
deliver safe patient care as these are essential staff and would be above the agreed planned
hours. The data therefore should not be looked at in isolation but be considered in line with
the shift red amber green (RAG) ratings exception report. See tables 1–3 below for the
comparison data and trends overall in the trust and then by hospital.
Table 1 – West Hertfordshire Hospitals overall percentage of filled against unplanned hours
Average Fill Rate
West Herts Trust Overall
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
July
Trained Nurses/
Midwives Day
100.8%
97.9%
97.9%
Trained Nurses/
Midwives Night
99.0%
99.1%
98.8%
Health Care
Assistants Day
99.8%
99.0%
103.1%
Health Care
Assistants Night
108.2%
100.3%
104.5%
Target Fill Rate
100.0%
100.0%
100.0%
August
Septemb
er
October
100.0%
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Table 2 – St Albans City Hospital percentage of hours filled against unplanned
Average Fill Rate
St Albans City Hospital
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
July
Trained Nurses/
Midwives Day
106.5%
103.7%
107.9%
Trained Nurses/
Midwives Night
97.5%
101.0%
100.0%
Health Care
Assistants Day
98.2%
101.7%
120.5%
Health Care
Assistants Night
100.0%
90.0%
96.8%
Target Fill Rate
100.0%
100.0%
100.0%
August
Septembe
r
October
100.0%
100.0%
100.0%
Novembe
December
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Table 3 – Watford General Hospital percentage of hours filled against planned
Average Fill Rate
Watford General Hospital
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
July
Trained Nurses/
Midwives Day
100.5%
97.7%
97.5%
Trained Nurses/
Midwives Night
99.0%
99.0%
98.8%
Health Care
Assistants Day
99.8%
98.9%
102.5%
Health Care
Assistants Night
108.4%
100.5%
104.7%
Target Fill Rate
100.0%
100.0%
100.0%
August
Septembe
r
October
100.0%
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Monthly comparison data and trends of the percentage of filled hours against planned by
division is shown in tables 4–6 below.
Table 4 - Medicine percentage of filled hours against planned
Average Fill Rate
Medicine
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
July
Trained Nurses/
Midwives Day
101.5%
97.7%
99.4%
Trained Nurses/
Midwives Night
99.0%
98.7%
98.6%
Health Care
Assistants Day
105.9%
104.4%
108.9%
Health Care
Assistants Night
116.0%
107.1%
115.8%
Target Fill Rate
100.0%
100.0%
100.0%
August
Septembe
r
October
100.0%
100.0%
100.0%
Novembe
December
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Table 5 – Surgery percentage of hours filled hours against planned
Avergae Fill Rate
Surgery
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
July
Trained Nurses/
Midwives Day
101.6%
99.8%
99.3%
Trained Nurses/
Midwives Night
97.1%
98.9%
97.9%
Health Care
Assistants Day
102.9%
98.3%
101.8%
Health Care
Assistants Night
127.2%
100.8%
106.5%
Target Fill Rate
100.0%
100.0%
100.0%
August
100.0%
Septembe
October
r
100.0%
Novembe Decembe
r
r
100.0%
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Table 6 - Womens and Childrens percentage of filled hours against planned
Average Fill Rate
Womens & Childrens
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
July
Trained Nurses/
Midwives Day
98.7%
96.4%
93.5%
Trained Nurses/
Midwives Night
100.2%
100.2%
100.0%
Health Care
Assistants Day
75.6%
81.8%
85.8%
Health Care
Assistants Night
79.7%
83.2%
75.6%
Target Fill Rate
100.0%
100.0%
100.0%
August
Septemb
er
October
100.0%
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
3.7 Across all ward and departments there were 2,370 day and night shifts 2,307 shifts were
rated green, 63 rated amber and 0 shifts were rated red in July 2014. See appendix 2 for
monthly detail by ward/department which also includes areas not in the unify data reporting.
The trust overall saw a reduction in amber ratings during the month of July Shifts rated
amber decreased by 1.87% from the previous month. See table 1 below for monthly trends.
Table 1 - West Hertfordshire Trust overall percentage shift RAG rating.
RAG Percentage
West Herts Trust Overall
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
May
June
July
Green
98.0%
95.39%
97.3%
Amber
2.0%
4.57%
2.7%
Red
0.0%
0.04%
0.0%
100.0%
100.0%
100.0%
Target RAG
August
Septembe
r
October
100.0%
100.0%
100.0%
November December
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
The division of Women’s and children’s reported a decrease in amber rated shifts by 10.2%
however the divisions of Medicine and Surgery reported an increase of amber rated shifts in
July, 0.3% in medicine and 2.4% in Surgery. See tables 2-4 below for comparison data.
Table 2 - Medicine monthly percentage shift RAG rating
RAG Percentage
Medicine
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
May
June
July
Green
99.0%
98.0%
97.7%
Amber
1.0%
2.0%
2.3%
Red
0.0%
0.0%
0.0%
100.0%
100.0%
100.0%
Target RAG
August
Septembe
r
October
100.0%
100.0%
100.0%
November December
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Table 3 - Surgery monthly percentage shift RAG rating
RAG Percentage
Surgery
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
May
June
July
Green
99.0%
98.6%
96.5%
Amber
1.0%
1.1%
3.5%
Red
0.0%
0.2%
0.0%
100.0%
100.0%
100.0%
Target RAG
August
Septembe
r
October
100.0%
100.0%
100.0%
November December
100.0%
100.0%
Table 4 – Women and children’s monthly percentage shift RAG rating
RAG Percentage
Womens and Childrens
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
May
June
July
Green
95.0%
87.0%
97.2%
Amber
5.0%
13.0%
2.8%
Red
0.0%
0.0%
0.0%
100.0%
100.0%
100.0%
Target RAG
August
Septembe
r
October
100.0%
100.0%
100.0%
Novembe
December
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
3.8 All areas who rated amber on a day or night shift took action to mitigate any risks to
maintain patient safety. Appendix 3 provides the detail for the safe staffing exception report
for July 2014, by division and ward, with mitigations to maintain safe staffing on the amber
rated days.
3.9 A total of 795.5 band 7 supervisory hours were lost in the month of July mitigating
unfilled hours to maintain safe patient care within the adult in patient wards. This will be
monitored closely over the coming months to identify trends in clinical areas that may impact
on the ability of the Band 7 to carry out their supervisory role and responsibilities.
4. Risks
4.1 There will be times when patients are admitted with higher acuity that require a higher
level of staff than the agreed requirement, ie 1:1 nursing.
4.2 Data is currently sourced from both electronic and manual data entry to enable
ratification of robust data collection. User error and administrative failure pose a risk to data
quality.
5. Recommendations
5.1 The committee is asked to:

Note the information and assurance

Note the ongoing work and actions
Tracey Carter Chief Nurse
15th August 2014
Appendix A
West Hertfordshire Hospitals Unify Fill rate indicator return Staffing: Nursing, midwifery and care staff July 2014
Day
Night
Registered
midwives/nurses
Site
Code
Total monthly
planned staff
hours
Site
Name
St
Albans
City
RWG03 Hospital 1906
Watford
General
RWG02 Hospital 50621
Care
Staff
Total
monthly
actual
staff
hours
Total
monthly
planned
staff
hours
Registered
midwives/nurses
Total
monthly
actual Total monthly
staff
planned staff
hours
hours
Care
Staff
Total
monthly
actual
staff
hours
Total
monthly
planned
staff
hours
2056
892.5
1075.5
1207.5
1207.5
49377
25894
26552
44263.5
43711.5 18285
West Hertfordshire Hospitals Unify Fill rate indicator return by ward July 2014
356.5
Day
Total
monthly
actual
staff
hours
Night
Average fill rate registered
nurses/midwives
(%)
Average
fill rate care
staff (%)
Average fill rate registered
nurses/midwives
(%)
Average
fill rate care
staff (%)
107.9%
120.5% 100.0%
96.8%
97.5%
102.5% 98.8%
104.7%
345
19136
Day
Hospital Site Details
Site code *The
Site code is
automatically
populated when
a Site name is
selected
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G03
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
RW G02
Main 2 Specialties on each ward
Ward name
Hospital Site name
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
St Albans City Hospital RW G03
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
RW G02
W atford General Hospital
Specialty 1
-
-
300 - GENERAL
MEDICINE
300 - GENERAL
AAU Yellow Level 1
MEDICINE
300 - GENERAL
AAU Green Level 1
MEDICINE
300 - GENERAL
AAU Red Suite
MEDICINE
300 - GENERAL
AAU Blue Level 3
MEDICINE
300 - GENERAL
AAU Yellow Level 3
MEDICINE
AAU Green & Purple 300 - GENERAL
Level 3
MEDICINE
430 - GERIATRIC
Bluebell
MEDICINE
430 - GERIATRIC
W inyard
MEDICINE
430 - GERIATRIC
Sarratt
MEDICINE
430 - GERIATRIC
Croxley
MEDICINE
Coronary Care Unit
320 - CARDIOLOGY
(CCU)
AAU Blue Level 1
300 - GENERAL
MEDICINE
370 - MEDICAL
Gade
ONCOLOGY
300 - GENERAL
Heronsgate
MEDICINE
300 - GENERAL
Aldenham
MEDICINE
Acute Stroke Unit
300 - GENERAL
W atford
MEDICINE
100 - GENERAL
De La Mare/Beckett
SURGERY
100 - GENERAL
Letchmore
SURGERY
100 - GENERAL
Ridge
SURGERY
100 - GENERAL
Flaunden
SURGERY
100 - GENERAL
Cleves
SURGERY
100 - GENERAL
Langley
SURGERY
192 - CRITICAL
Combined ITU
CARE MEDICINE
321 - PAEDIATRIC
Starfish
CARDIOLOGY
321 - PAEDIATRIC
SCBU
CARDIOLOGY
502 Elizabeth W ard
GYNAECOLOGY
Cassio
Specialty 2
Registered
midwives/nurses
Night
Care Staff
Day
Registered
midwives/nurses
Night
Care Staff
Average fill
rate Average fill
registered rate - care
Total
Total
Total
Total
Total
Total
Total
Total
monthly
monthly
monthly
monthly
monthly
monthly
monthly
monthly nurses/mid staff (%)
planned
actual staff planned actual staff planned actual staff planned actual staff wives (%)
staff hours hours
staff hours
hours
staff hours
hours
staff hours
hours
Average fill
rate Average fill
registered rate - care
nurses/mid staff (%)
wives (%)
1174.5
1120.5
713
747.5
1069.5
1058
713
736
95.4%
104.8%
98.9%
103.2%
1197
1177.5
713
713
1069.5
1058
713
736
98.4%
100.0%
98.9%
103.2%
1219.5
1204
713
839.5
1069.5
1069.5
713
793.5
98.7%
117.7%
100.0%
111.3%
1219.5
1215.5
713
736
1069.5
1069.5
356.5
379.5
99.7%
103.2%
100.0%
106.5%
1456
1417.5
1069.5
1046.5
1426
1403
713
701.5
97.4%
97.8%
98.4%
98.4%
1219.5
1211.5
713
747.5
1069.5
1035
356.5
460
99.3%
104.8%
96.8%
129.0%
1833
1810
1426
1460.5
1426
1391.5
713
770.5
98.7%
102.4%
97.6%
108.1%
1583.5
1587
1426
1437.5
1426
1437.5
1426
1460.5
100.2%
100.8%
100.8%
102.4%
1197
1185.5
713
674.5
1069.5
1035
713
759
99.0%
94.6%
96.8%
106.5%
1917.5
2008
1658.5
2150
1782.5
1679
1069.5
1736.5
104.7%
129.6%
94.2%
162.4%
1583.5
1636
1302
1467.5
1426
1426
1069.5
1173
103.3%
112.7%
100.0%
109.7%
1531
1519.5
264.5
241.5
1426
1403
0
23
99.2%
91.3%
98.4%
#DIV/0!
1234.5
1207.5
713
977.5
1069.5
1058
356.5
632.5
97.8%
137.1%
98.9%
177.4%
1212
1231
713
874
1069.5
1058
356.5
483
101.6%
122.6%
98.9%
135.5%
1204.5
1196
828
851
1069.5
1069.5
356.5
460
99.3%
102.8%
100.0%
129.0%
2093.5
2047.5
1265
1368
1955
1943.5
540.5
621
97.8%
108.1%
99.4%
114.9%
2630.5
2580.5
1302
1352
2495.5
2484
1069.5
1081
98.1%
103.8%
99.5%
101.1%
1906
2056
892.5
1075.5
1207.5
1207.5
356.5
345
107.9%
120.5%
100.0%
96.8%
1182
1154
713
690
1069.5
1069.5
356.5
356.5
97.6%
96.8%
100.0%
100.0%
1568.5
1583.5
1069.5
989
1069.5
1000.5
713
713
101.0%
92.5%
93.5%
100.0%
1591
1587
1069.5
1069.5
1426
1288
356.5
425.5
99.7%
100.0%
90.3%
119.4%
1227
1245.5
1069.5
1044
1069.5
1058
356.5
529
101.5%
97.6%
98.9%
148.4%
1135
1058.5
448.5
536.5
713
678.5
356.5
345
93.3%
119.6%
95.2%
96.8%
5428
5251.5
356.5
318
5186.5
5198
333.5
299
96.7%
89.2%
100.2%
89.7%
1334
1312.5
356.5
371.5
1069.5
977.5
356.5
310.5
98.4%
104.2%
91.4%
87.1%
2219.5
2323
1000.5
724
2185
2369
1012
540.5
104.7%
72.4%
108.4%
53.4%
1553.5
1582
713
677
1069.5
1069.5
713
609.5
101.8%
95.0%
100.0%
85.5%
Delivery Suite
501 - OBSTETRICS
3613.5
3278.5
713
590.5
3208.5
3151
713
517.5
90.7%
82.8%
98.2%
72.6%
ABC
501 - OBSTETRICS
1302
1105
356.5
336.5
1069.5
1058
356.5
287.5
84.9%
94.4%
98.9%
80.6%
Victoria
501 - OBSTETRICS
945.5
704.5
356.5
370.5
713
713
356.5
322
74.5%
103.9%
100.0%
90.3%
-
Appendix B Number of day and night shifts (includes long days early and late shifts) planned against actual on duty July 2014.
Please note the actual staff on duty would include staff unplanned but essential to maintain patient safety e.g. 1:1 specials and staff rostered and working clinically on a period
of supervision (orientation). These staff would be in addition to the planned staffing levels and distort the actual required staffing levels
No. of Day
Shifts
Division
Planned
Medicine
Women's & Childrens
Surgery
Paediatrics
Gynaecology
Maternity
No. of Night
Shifts
No. of Day
Shifts
No. of Night
Shifts
Area
AAU Blue Level 1
AAU Yellow Level 1
AAU Green Level 1
AAU Red Suite
AAU Triage
AAU Blue Level 3
AAU Yellow Level 3
AAU Green & Purple L3
Bluebell
Winyard
A&E
UCC Hemel
MIU SACH
Sarratt
Croxley
CCU
Cassio
Gade
Heronsgate
Aldenham
Acute Stroke Unit
Total
Beckett
De La Mare
Letchmore
Flaunden
Ridge
Cleves
Langley
Combined ITU
Total
Starfish
CED
Safari Day Unit
Neonatal Unit
Transitional Care Unit
Elizabeth
Delivery Suite
Alexandra BC
Victoria
Katherine
Knutsford
Total
107
110
113
113
187
128
113
166
145
110
310
93
62
173
145
138
115
112
111
189
235
2975
30
139
108
146
143
114
106
472
1258
116
124
62
190
3
141
333
124
93
155
31
1372
Appendix C
July 2014 Trust safe staffing exception report
Nursing & Midwifery Professional Judgement safe staffing RAG Rates
Actual
Planned
Registered Nurses/Midwives
103
93
109
93
112
93
113
93
163
93
125
124
113
93
164
124
146
124
109
93
305
310
93
62
62
0
184
155
152
124
137
124
113
93
114
93
112
93
185
170
231
217
2945
2464
36
12
156
93
108
93
146
124
145
93
117
93
99
62
457
451
1264
1021
119
93
129
93
67
0
177
189
20
1
148
93
318
279
120
93
76
62
153
93
30
31
1357
1027
Actual
92
92
93
93
92
122
90
121
125
90
318
62
0
146
124
122
92
92
93
169
216
2444
12
93
93
112
87
92
59
452
1000
85
90
0
186
15
93
274
92
62
91
31
1019
Planned
62
62
62
62
92
93
62
124
124
62
124
31
0
155
124
23
62
62
72
110
93
1661
13
62
62
93
93
93
39
31
486
31
0
23
29
58
62
62
31
31
93
31
451
Actual
Planned
Healthcare Assistants
65
62
62
62
73
62
64
31
100
62
91
62
65
31
127
62
125
124
59
62
119
62
31
0
0
0
188
93
137
93
21
0
85
31
76
31
74
31
120
47
128
93
1810
1101
17
0
88
31
60
31
93
31
86
62
96
31
47
31
28
29
515
246
33
31
1
0
18
0
26
27
39
61
62
62
69
62
35
31
38
31
81
62
31
31
433
398
Actual
64
64
69
33
59
61
40
67
127
66
60
0
0
151
102
2
55
42
40
54
94
1250
0
30
31
37
62
46
30
26
262
27
1
0
8
40
53
45
25
28
51
25
303
Green - Staffing numbers are as expected on the rota and ward is assessed as being safely staffed taking into consideration workload and patient acuity. Staffing numbers are not as expected
but safe according to current workload.
Amber - Staffing numbers are not as expected and minor adjustments need to be made to bring staffing to a reasonable level given workload and acuity or staffing numbers are as expected
but given workload and acuity additional staff are required.
Red - Staffing levels inadequate to cope with current patient needs.
Division
Area
Date
Shift
Professional
Judgement
Rag Rating
AAU Blue
L1
19/07/2014
Day
A
05/07/2014
Day
A
Down an RN in the day shift out to nhsp/agency not covered. Triage will help to support
17/07/2014
Day
A
Band 7 in the numbers till 3pm. 1x Pts on bipap. 18 iv medication and one nurse does IV's
19/07/2014
Day
A
Band 7 to support in Triage
21/07/2014
Night
A
1 HCA down at night. Support from Green L1
22/07/2014
Day
A
2 nurses short for the long day, senior sister will be working in the number on long day. Extra hca
AAU
Yellow L1
28/07/2014
Day
A
Band 7 to support.
29/07/2014
Day
A
1 RN down for the day shift. Band 6 in the numbers
Bluebell
14/07/2014
Day
A
Band 7 working in the numbers, Winyard ward to support as required
Winyard
22/07/2014
Day
A
x1 RN out to agency. Band 7 on late shift. Bluebell ward to support
18/07/2014
Day
A
22/07/2014
Day
A
enp needed to be sent to UCC to ensure UCC was safe.
31/07/2014
Day
A
staff moved to ensure all areas covered Clinical facilitator worked in the department. Agency nurses arrived very late.
AAU Green
L1
Medicine
AAU Triage
A&E
Comments, Mitigation - Actions taken to Ensure safe Staffing Levels
Band 7 to provide support to the staff
PDN to support clinically no band 7. Medical staff to cover ANP workload. Trying to rearrange night ANP to come in early
Acute
Stroke Unit
11/07/2014
Day
A
3 trained sick but 1 is covered by agency. 1 overseas nurse without PIN working as HCA. Currently 7 empty beds which helps with safety but will become more
difficult if we start admitting. 1 HCA sent to support ward. No further trained staff available. maintained 8 empty beds throughout day but acuity reflects
amber rating
Aldenham
19/07/2014
Day
A
nurse awaiting pin number - supernumerary working in the numbers
Cassio
06/07/2014
Day
A
13/07/2014
Day
A
06/07/2014
Night
A
21/07/2014
Night
A
29/07/2014
Day
A
CCU
1RN DNA on a LD; 1 CSW worked from another ward from 0945. 1 Special CSW LD and N
X 1 special Agency R/N DNA. NHSP informed, on duty were 2 sisters from the ward 2 CSW from the ward and senior nurse on call sent a Csw to ward
senior sister can be contacted for support, shift out to NHSP, Bed manager informed x1 RN short.
unconfirmed booking for agency HCA (LD). Band 5 swapped with HCA as Gade ward short. Band 7 can be contacted for support
1 staff nurse short, out to NHSP. Matron informed. Band 7 can be contacted for support.
Croxley
x2 specials booked but did not turn up for duty. Support from Sarratt ward
19/07/2014
Day
A
10/07/2014
Day
A
12/07/2014
Night
A
21/07/2014
Day
A
22/07/2014
Day
A
04/07/2014
Day
A
05/07/2014
Day
A
27/07/2014
Day
A
unfilled shift on long day it is out to agency, awaiting to see if it fills. Tried to move staff to cover unable to. Escalated to bed manager and on call sister.
19/07/2014
Day
A
RN cancelled long day. 3rd year student supported vacant shift
15/07/2014
Day
A
Outreach nurse was required to work in ITU during day shift to support the unit.
19/07/2014
Night
A
21/07/2014
Night
A
Admitted ward patients as hospital full, unable to admit electives , outreach service suspended to take patients. Escalated to Matron +Site manager unit safe..
Night Comment: Outreach service should be re-established overnight. No capacity for level 3 admission. No level 1 patients on ITU.
26/07/2014
Night
A
Unit full with 19 patients no ward patients. Escalated to Matron . Staffing safe.
22/07/2014
Day
A
28/07/2014
Night
A
4th trained cancelled late pm with nhsp and not replaced. Took tap from ridge ward = 3 + 2
30/07/2014
Night
A
one RGN has cancelled at 03.30. was escalated on a5 authorised shift out to nhsp not covered. B2 spare overnight covered it via bed manager authorisation.
01/07/2014
Night
A
05/07/2014
Day
A
One R.N short. Poor skill mix on ward and in ESAL, Bed manager made aware . Band 4 Tap Nurse on duty today. Additional R.N for late shift.
14/07/2014
Day
A
RN sick LD, escalated to matron, band 7 counted in numbers for early, HCA relocated from another ward, RN shift requested from NHSP
19/07/2014
Day
A
One HCA on Sick leave. Bleep holder and bed manager made aware at 20:00 on 18/7/14. Shift placed on NHS Professionals not currently filled. Shift time
changed to 10:00, Shift to be "unlocked" for agency this morning. Will share 10:00 to 22:00 nurse with ESAU.
21/07/2014
Day
A
band 6 sick LD, band 7 counted in numbers early shift, will escalate to matron
25/07/2014
Day
A
1 RN sick LD, band 7 incuded in numbers AM, will escalate to matron
30/07/2014
Day
A
1 RN sick for LD, band 7 counted in numbers. 2nd RN in ESAU to work between ward and ESAU. 1 CSW is an assisted practitioner who can take a bay
19/07/2014
Night
A
1 hca short,senior nurse on call informed. Healthcare from Langley ward assisted when needed
20/07/2014
Night
A
one HCA short on the LD and require special for LD CSW this was escalated to senior nurse no help available
1 HCA special for patient. 1 RN SHIFT OUT STANDING escalated to senior nurse no other staff member available to help.
Gade
Heronsgate
Sarratt
Surgery
ITU
De La Mare
Flaunden
Letchmore
Ridge
Ward will be one RN down on the late shift due to cancellation by bank. Supervisory in the numbers
1 RN short was required for escort. No help available used ward staff, this left the ward short. This was escalated to senior nurse, no help available
Have 2 patients that require 1:1, one patient has special book which has not been covered on NHSP, 2nd patient has become confused over night, after
speaking with staff have requested special as they have needed staff memeber with her at all times. escalated to Matron, senior sister stepped into bay.
Extra HCA for special for confused staff. Agency nurse DNA shift, supervisory stepped into bay, escalated to matron
x1 agency nurse cancelled late. Outreach nurse pulled out to work on unit. X1 agency ward trained nurse booked in to help.
1 RN sick on a long day, covered the late shift and Beckett closing this pm and staff will come up to De la Mare
liaise with matron as senior nurse for night shift has commenced paternity leave which leaves only junior staff on the ward
1 R/N short.Senior nurse on call informed. ,unable to get trained,extra hca sent by bleepholder during the night
Paediatrics
CED
Gynaecology
Starfish
Mater
nity
Womens & Childrens
Safari
Elizabeth
Delivery
Suite
02/07/2014
Day
A
Risk mitigated by Senior sister and moving staff around the service.
14/07/2014
Night
A
Night out to agencies. Not filled but staff on ward and A&E aware and covered as required.
15/07/2014
Night
A
MLD out to agencies. A&E and Starfish aware and can help as required
18/07/2014
Night
A
Starfish and A&E aware, will support if needed. Senior Sister on call aware. Agency not filled.
20/07/2014
Day
A
MLD one staff nurse short due to sickness. A&E and Ward aware that help may be required.
22/07/2014
Night
A
out to agency. Agency filled
27/07/2014
Night
A
x1 member of nursing team on N is newly qualified, awaiting PIN. A&E and Starfish aware, will support if needed
23/07/2014
Day
A
Senior Sister assisting on ward
09/07/2014
Night
A
Ced aware and able to assist through the night if needed .Senior nurse on-call available via telephone.
10/07/2014
Night
A
Night shift down to last minute sickness. Senior nurse on call aware and available by phone for advice.Ced available toprovide help if needed.
11/07/2014
Day
A
09/07/2014
Day
A
x1 HCA doing the housekeepers job. X6 electives to come in, only 1 bed at present. X1 medical management of miscarriage to bring in and the nurse special
not filled for that.
14/07/2014
Day
A
Band 5 not covered and Band 2 DNA.Band 2 early for housekeper. Staff split to 2 bays each and all discharges/admissions to be completed by 2pm to mitigate
risk from returning afternoon list
17/07/2014
Day
A
x1 RN shift outstanding. X2 medical managements of miscarriages coming in today and they are usually specialled and they will heighten the activity on the
ward. Band 7 to assist on the ward
19/07/2014
Day
A
x1 RN phoned in sick in the night. X 1 HCA went off sick late last night. Supernumerary trained nurse awaiting pin supporting clinically, HCA cover for 7.5 hours
of 11.5 hour shift
22/07/2014
Day
A
x1 HCA short. X 8 elective patients to bring in. Band 7 in the numbers
30/07/2014
Day
A
07/07/2014
Night
A
Staff sickness at short notice, x2 band 7's working on the ward to assist, CED and safari unit able to provide assistance where needed.
Only 3 nurses on the ward after 5pm. 6 electives to come in. 6 medical patients. 2 surgical patients. 4 breast patients. Supervisory in the numbers
one RM short on shift , high levels of activity, sit rep changed at 22:00, called in community as 9 x labouring Patients , 1HDU and high risk an patient requiring
1:1,informed matron and community midwifery manager, 10 deliveries between 22:00 and 04:00 including admission of a high risk CSF case, with violent
family connections and high flight risk. Safe staffing status now amber .
Appendix 3
Nursing and Midwifery Safe Staffing - Month 5
1. Purpose
1.1 This paper provides an update on the progress regarding the arrangements for
managing safe nursing and midwifery staffing levels within the inpatient wards during
August 2014.
2. Background
2.1 The Trust submitted all unify data to NHS England as required by the 9th
September 2014 which is available to view on NHS Choices website at the end of the
month. See Appendix A for August 2014 unify data by site and ward.
3. Analysis/Discussion
3.1 The Trust reported 1,633 unfilled hours for trained nurses and midwives and
1,124 hours unfilled against planned for health care assistants on day shifts. On night
shifts 402 hours were unfilled for trained nurses/midwives against the planned hours
required on duty, and for healthcare assistant 104 hours were on duty above planned
hours.
3.2 Comparison data and trends overall in the Trust can be seen in tables 1-3 below.
This comprises of all staff on duty including unplanned essential staff e.g. 1:1
specials. The overall fill rate shows a reduction from the previous month.
Table 1 – West Hertfordshire Hospitals - overall percentage of hours filled against
planned
Average Fill Rate
West Herts Trust Overall
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
July
August
Trained Nurses/
Midwives Day
100.8%
97.9%
97.9%
96.9%
Trained Nurses/
Midwives Night
99.0%
99.1%
98.8%
99.1%
Health Care
Assistants Day
99.8%
99.0%
103.1%
95.7%
Health Care
Assistants Night
108.2%
100.3%
104.5%
100.6%
Page 34 of 52
Septemb
er
October
Novembe Decembe
r
r
January
February
March
April
Table 2 – St Albans City Hospital - percentages of hours filled against planned
Average Fill Rate
St Albans City Hospital
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
July
August
Trained Nurses/
Midwives Day
106.5%
103.7%
107.9%
98.4%
Trained Nurses/
Midwives Night
97.5%
101.0%
100.0%
99.0%
Health Care
Assistants Day
98.2%
101.7%
120.5%
115.7%
Health Care
Assistants Night
100.0%
90.0%
96.8%
100.0%
Target Fill Rate
100.0%
100.0%
100.0%
100.0%
Septemb
er
October
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Table 3 – Watford General Hospital - percentages of hours filled against planned
Average Fill Rate
Watford General Hospital
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
July
August
Trained Nurses/
Midwives Day
100.5%
97.7%
97.5%
96.8%
Trained Nurses/
Midwives Night
99.0%
99.0%
98.8%
99.1%
Health Care
Assistants Day
99.8%
98.9%
102.5%
95.0%
Health Care
Assistants Night
108.4%
100.5%
104.7%
100.6%
Target Fill Rate
100.0%
100.0%
100.0%
100.0%
Septemb
er
October
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Monthly comparison data and trends of the percentage of filled hours against
planned by division is shown in tables 4–6 below.
Table 4 - Medicine percentage of filled hours against planned
Average Fill Rate
Medicine
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
July
August
Trained Nurses/
Midwives Day
101.5%
97.7%
99.4%
97.2%
Trained Nurses/
Midwives Night
99.0%
98.7%
98.6%
97.5%
Health Care
Assistants Day
105.9%
104.4%
108.9%
97.7%
Health Care
Assistants Night
116.0%
107.1%
115.8%
103.2%
Target Fill Rate
100.0%
100.0%
100.0%
100.0%
Page 35 of 52
Septemb
er
October
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Table 5 – Surgery percentage of hours filled hours against planned
Avergae Fill Rate
Surgery
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
July
August
Trained Nurses/
Midwives Day
101.6%
99.8%
99.3%
98.5%
Trained Nurses/
Midwives Night
97.1%
98.9%
97.9%
98.9%
Health Care
Assistants Day
102.9%
98.3%
101.8%
98.7%
Health Care
Assistants Night
127.2%
100.8%
106.5%
116.8%
Target Fill Rate
100.0%
100.0%
100.0%
100.0%
Septemb
er
October
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Table 6 - Womens and Childrens percentage of filled hours against planned
Average Fill Rate
Womens & Childrens
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
July
August
Trained Nurses/
Midwives Day
98.7%
96.4%
93.5%
94.0%
Trained Nurses/
Midwives Night
100.2%
100.2%
100.0%
102.8%
Health Care
Assistants Day
75.6%
81.8%
85.8%
85.8%
Health Care
Assistants Night
79.7%
83.2%
75.6%
84.9%
Target Fill Rate
100.0%
100.0%
100.0%
100.0%
Septemb
er
October
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
3.3 Some clinical areas are noted to have an increase in hours above planned for
health care assistants due to fluctuations in the acuity or dependency of patients on
some shifts e.g. 1:1 specials and escorts.
3.4 Across all wards and departments there were 2,363 day and night shifts of these
2,261 shifts were rated green, 102 rated amber and 0 shifts were rated red. See
appendix B for monthly detail by ward/department which also includes areas not in
the unify data reporting.
3.5 There was a 1.6% increase in amber ratings during the month of August. See
table 1 below for monthly trends.
Table 1 - West Hertfordshire Trust overall percentage shift RAG rating.
Average Fill Rate
West Herts Trust Overall
140.0%
130.0%
120.0%
110.0%
100.0%
90.0%
80.0%
70.0%
60.0%
May
June
July
August
Trained Nurses/
Midwives Day
100.8%
97.9%
97.9%
96.9%
Trained Nurses/
Midwives Night
99.0%
99.1%
98.8%
99.1%
Health Care
Assistants Day
99.8%
99.0%
103.1%
95.7%
Health Care
Assistants Night
108.2%
100.3%
104.5%
100.6%
Target Fill Rate
100.0%
100.0%
100.0%
100.0%
Page 36 of 52
Septemb
er
October
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
3.6 The division of Medicine reported an increase in amber rated shifts of 1.6%,
Surgery a decrease of 0.6% and Women’s and children’s an increase of 1.7% in
August from the previous month. See tables 2-4 below for comparison data.
Table 2 - Medicine monthly percentage shift RAG rating
RAG Percentage
Medicine
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
May
June
July
August
Green
99.0%
98.0%
97.7%
95.3%
Amber
1.0%
2.0%
2.3%
4.7%
Red
0.0%
0.0%
0.0%
0.0%
100.0%
100.0%
100.0%
100.0%
Target RAG
Septemb
er
October
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
Table 3 - Surgery monthly percentage shift RAG rating
RAG Percentage
Surgery
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
May
June
July
August
Green
99.0%
98.6%
96.5%
97.1%
Amber
1.0%
1.4%
3.5%
2.9%
Red
0.0%
0.0%
0.0%
0.0%
100.0%
100.0%
100.0%
100.0%
Target RAG
Septembe
r
October
100.0%
100.0%
Novembe Decembe
r
r
100.0%
100.0%
Table 4 – Women and children’s monthly percentage shift RAG rating
RAG Percentage
Womens and Childrens
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
May
June
July
August
Green
95.0%
87.0%
97.2%
95.5%
Amber
5.0%
13.0%
2.8%
4.5%
Red
0.0%
0.0%
0.0%
0.0%
100.0%
100.0%
100.0%
100.0%
Target RAG
Septembe
r
October
100.0%
100.0%
Novembe
December
r
100.0%
100.0%
January
February
March
April
100.0%
100.0%
100.0%
100.0%
3.7 All areas who rated amber on a day or night shift took action to mitigate any risks
to maintain patient safety. Appendix C provides the detail for the safe staffing
exception report for August 2014, by division and ward, with mitigations to maintain
safe staffing on the amber rated days.
Page 37 of 52
3.8 A total of 862.5 band 7 supervisory hours were lost in the month of August
mitigating unfilled hours to maintain safe patient care within the adult in patient
wards. This was an increase of 67 hours on the previous months.
4. Risks
4.1 There will be times when patients are admitted with higher acuity that require a
higher level of staff than the agreed requirement, i.e. 1:1 nursing.
4.2 Data is currently sourced from both electronic and manual data entry to enable
ratification of robust data collection. User error and administrative failure pose a risk
to data quality.
5. Recommendations
5.1 The committee is asked to:

Note the information and assurance
Tracey Carter Chief Nurse and DIPC
15th September 2014
Page 38 of 52
Appendix A
West Hertfordshire Hospitals Unify Fill rate indicator return Staffing: Nursing, midwifery and care staff August 2014
Day
Night
Registered
midwives/nurses
Site
Code
Site Name
St Albans City
RWG03 Hospital
Watford General
RWG02 Hospital
Page 39 of 52
Care
Staff
Registered
midwives/nurses
Care
Staff
Day
Total monthly
planned staff
hours
Total
monthly
actual
staff
hours
Total
monthly
planned
staff
hours
Total
monthly
actual
Total monthly
staff
planned staff
hours
hours
Total
monthly
actual
staff
hours
Total
monthly
planned
staff
hours
Total
monthly
actual
staff
hours
1811
1782
862.5
998
1184.5
1173
345
345
50078
48474
25951.5
24666.5
44631.5
44240.5
18147
18250.5
Night
Average fill rate registered
nurses/midwives
(%)
Average
fill rate care staff
(%)
Average fill rate registered
nurses/midwives
(%)
Average
fill rate care staff
(%)
98.4%
115.7%
99.0%
100.0%
96.8%
95.0%
99.1%
100.6%
West Hertfordshire Hospitals Unify Fill rate indicator return by ward August 2014
Day
Hospital Site Details
Main 2 Specialties on each ward
Registered midwives/nurses
Care Staff
Specialty 1
Total monthly
planned staff
hours
Total monthly
planned staff
hours
Ward name
Site code
RWG0
RWG02
RWG02
Hospital Site name
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
RWG02
AAU Blue Level 1
AAU Yellow Level 1
AAU Green Level 1
AAU Red Suite
Watford General Hospital - RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG03
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
St Albans City Hospital - RWG03
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
Watford General Hospital - RWG02
RWG02
Watford General Hospital - RWG02
Page 40 of 52
300 - GENERAL
MEDICINE
300 - GENERAL
MEDICINE
300 - GENERAL
MEDICINE
300 - GENERAL
MEDICINE
Elizabeth Ward
Delivery Suite
ABC
Victoria
Katherine
300 - GENERAL
MEDICINE
300 - GENERAL
MEDICINE
300 - GENERAL
MEDICINE
430 - GERIATRIC
MEDICINE
430 - GERIATRIC
MEDICINE
430 - GERIATRIC
MEDICINE
430 - GERIATRIC
MEDICINE
320 - CARDIOLOGY
300 - GENERAL
MEDICINE
370 - MEDICAL
ONCOLOGY
300 - GENERAL
MEDICINE
300 - GENERAL
MEDICINE
300 - GENERAL
MEDICINE
100 - GENERAL
SURGERY
100 - GENERAL
SURGERY
100 - GENERAL
SURGERY
100 - GENERAL
SURGERY
100 - GENERAL
SURGERY
100 - GENERAL
SURGERY
192 - CRITICAL CARE
MEDICINE
321 - PAEDIATRIC
CARDIOLOGY
321 - PAEDIATRIC
CARDIOLOGY
502 - GYNAECOLOGY
501 - OBSTETRICS
501 - OBSTETRICS
501 - OBSTETRICS
501 - OBSTETRICS
Knutsford
501 - OBSTETRICS
AAU Blue Level 3
AAU Yellow Level 3
AAU Green & Purple Level 3
Bluebell
Winyard
Sarratt
Croxley
Coronary Care Unit (CCU)
Cassio
Gade
Heronsgate
Aldenham
Acute Stroke Unit Watford
De La Mare/Beckett
Letchmore
Ridge
Flaunden
Cleves
Langley
Combined ITU
Starfish
SCBU
Night
Specialty 2
Total monthly
actual staff hours
Total monthly
actual staff
hours
Registered midwives/nurses
Care Staff
Total monthly
planned staff
hours
Total monthly
planned staff
hours
Total monthly
actual staff hours
Total monthly actual
staff hours
Day
Night
Average fill rate
- registered
Average fill rate
nurses/midwive - care staff (%)
s (%)
Average fill rate
Average fill
- registered
rate - care
nurses/midwive
staff (%)
s (%)
1148.5
1064
713
724.5
1069.5
1058
713
690
92.6%
101.6%
98.9%
96.8%
1122
12060.5
713
713
1069.5
1069.5
713
736
94.5%
100.0%
100.0%
103.2%
1167
1097
713
724
1069.5
989
713
690
94.0%
101.5%
92.5%
96.8%
1219.5
1208
713
713
1069.5
1081
356.5
460
99.1%
100.0%
101.1%
129.0%
1441
1360.5
1069.5
1035
1426
1380
713
713
94.4%
96.8%
96.8%
100.0%
1204.5
1166
713
690
1069.5
1058
356.5
356.5
96.8%
96.8%
98.9%
100.0%
1787.5
1718.5
1426
1368.5
1426
1403
713
713
96.1%
96.0%
98.4%
100.0%
1568.5
1522.5
1426
1380
1426
1414.5
1426
1460.5
97.1%
96.8%
99.2%
102.4%
1183
1075.5
713
713
1069.5
1023.5
713
724.5
90.9%
100.0%
95.7%
101.6%
1932.5
2063.5
1658.5
1376
1782.5
1771
1069.5
1115.5
106.8%
83.0%
99.4%
104.3%
1568.5
1579
1302
1207.5
1426
1391.5
1069.5
966
100.7%
92.7%
97.6%
90.3%
1546
1488.5
241.5
264.5
1426
1380
0
23
96.3%
109.5%
96.8%
#DIV/0!
1189.5
1178
713
816.5
1069.5
1058
356.5
460
99.0%
114.5%
98.9%
129.0%
1189.5
1170
713
713
1069.5
1023.5
356.5
356.5
98.4%
100.0%
95.7%
100.0%
1212
1223.5
805
805
1069.5
1058
356.5
345
100.9%
100.0%
98.9%
96.8%
2059.5
1971
1276.5
1345.5
2139
2012.5
356.5
552
95.7%
105.4%
94.1%
154.8%
2600.5
2504.5
1302
1252.5
2495.5
2426.5
1069.5
1046.5
96.3%
96.2%
97.2%
97.8%
1811
1782
862.5
998
1184.5
1173
345
345
98.4%
115.7%
99.0%
100.0%
1174.5
1205
713
698
1069.5
1058
356.5
391
102.6%
97.8%
98.9%
109.7%
1553.5
1507
1069.5
931.5
1069.5
1058
713
713
97.0%
87.1%
98.9%
100.0%
1561
1518.5
1069.5
1100
1426
1403
356.5
414
97.3%
102.9%
98.4%
116.1%
1189.5
1189
1069.5
997.5
1069.5
1046.5
356.5
736
100.0%
93.3%
97.8%
206.5%
1082
1051
471.5
471.5
713
701.5
356.5
333.5
97.1%
100.0%
98.4%
93.5%
5566
5481.5
356.5
345
5416.5
5382
322
322
98.5%
96.8%
99.4%
100.0%
1311
1180
356.5
345
1069.5
1069.5
356.5
333.5
90.0%
96.8%
100.0%
93.5%
2139
2426.5
1069.5
713
2139
2541.5
1069.5
563.5
113.4%
66.7%
118.8%
52.7%
1508.5
3591
1302
945.5
1658.5
1521.5
3325.5
1070
719.5
1476.5
713
713
356.5
356.5
1069.5
731.5
646.5
357.5
310.5
844.5
1069.5
3208.5
1069.5
713
1069.5
1058
3151
1046.5
690
1081
713
713
356.5
356.5
713
701.5
655.5
287.5
333.5
701.5
100.9%
92.6%
82.2%
76.1%
89.0%
102.6%
90.7%
100.3%
87.1%
79.0%
98.9%
98.2%
97.8%
96.8%
101.1%
98.4%
91.9%
80.6%
93.5%
98.4%
356.5
352.5
356.5
333.5
356.5
356.5
356.5
356.5
98.9%
93.5%
100.0%
100.0%
Appendix B - Number of day and night shifts (includes long days early and late shifts) planned against actual on duty August 2014.
Please note the actual staff on duty would include staff unplanned but essential to maintain patient safety e.g. 1:1 specials and staff rostered and working
clinically on a period of supervision (orientation). These staff would be in addition to the planned staffing levels and distort the actual required staffing levels
Division
No. of Day
Shifts
Planned
Actual
Area
No. of Night
Shifts
Planned
Actual
No. of Day
Shifts
Planned
Actual
Registered Nurses/Midwives
Healthcare Assistants
Medicine Overall
Surgery Overall
2919
1246
2844
1245
2480
1047
2433
1036
1659
488
1618
503
1085
245
1110
283
Womens & Childrens Overall
Trust Overall
1332
5497
1286
5375
1023
4550
1052
4521
435
2582
395
2516
403
1733
342
1735
Division
Area
No. of Day
Shifts
Planned
Actual
No. of Night
Shifts
Planned
Actual
No. of Day
Shifts
Planned
Actual
Registered Nurses/Midwives
Medicine
No. of Night
Shifts
Planned
Actual
Healthcare Assistants
AAU Blue Level 1
102
96
93
92
62
63
62
60
AAU Yellow Level 1
AAU Green Level 1
AAU Red Suite
100
106
113
95
103
112
93
93
93
93
87
94
62
62
62
62
64
62
62
62
31
64
60
40
AAU Triage
AAU Blue Level 3
186
126
160
119
93
124
92
120
93
93
79
90
62
62
60
62
AAU Yellow Level 3
AAU Green & Purple L3
Bluebell
111
161
143
108
155
139
93
124
124
92
122
124
62
124
124
60
119
120
31
62
124
31
62
127
Winyard
A&E
102
310
97
298
93
310
89
311
62
124
63
113
62
62
62
58
UCC Hemel
MIU SACH
93
62
92
61
62
0
62
0
31
0
31
0
0
0
0
0
Sarratt
Croxley
CCU
175
143
140
193
146
135
155
124
124
154
121
120
155
124
21
120
113
23
93
93
0
97
84
2
Cassio
Gade
109
109
108
109
93
93
92
89
62
62
71
62
31
31
40
31
Heronsgate
Aldenham
Acute Stroke Unit
112
185
231
2919
113
178
227
2844
93
186
217
2480
92
175
212
2433
70
111
93
1659
70
114
119
1618
31
31
93
1085
30
48
92
1110
Total
Page 41 of 52
No. of Night
Shifts
Planned
Actual
Division
Surgery
Area
Beckett
De La Mare
Letchmore
Flaunden
Ridge
Cleves
Langley
Combined ITU
Total
Women's & Childrens
Division
Paediatrics
Gynaecology
Maternity
Area
Starfish
CED
Safari Day Unit
Neonatal Unit
Transitional Care Unit
Elizabeth
Delivery Suite
Alexandra BC
Victoria
Katherine
Knutsford
Total
Page 42 of 52
No. of Day
No. of Night
Shifts
Shifts
Planned
Actual
Planned
Actual
Registered Nurses/Midwives
25
25
10
10
138
147
93
92
107
111
93
92
142
139
124
122
141
138
93
92
109
110
93
91
100
98
62
61
484
477
479
476
1246
1245
1047
1036
No. of Day
No. of Night
Shifts
Shifts
Planned
Actual
Planned
Actual
Registered Nurses/Midwives
114
104
93
93
124
130
93
94.5
40
52
0
0
186
199
186
207
0
12
0
14
135
141
93
93
330
305
279
274
124
105
93
91
93
68
62
60
155
139
93
94
31
31
31
31
1332
1286
1023
1052
No. of Day
No. of Night
Shifts
Shifts
Planned
Actual
Planned
Actual
Healthcare Assistants
13
16
0
0
62
85
31
30
62
61
31
34
93
96
31
36
93
81
62
62
93
93
31
64
41
41
31
29
31
30
28
28
488
503
245
283
No. of Day
No. of Night
Shifts
Shifts
Planned
Actual
Planned
Actual
Healthcare Assistants
31
30
31
29
0
0
0
0
1
7
0
0
31
18
31
6
62
44
62
43
62
65
62
61
62
59
62
57
31
37
31
25
31
27
31
29
93
79
62
61
31
29
31
31
435
395
403
342
Appendix C
July 2014 Trust safe staffing exception report
Nursing & Midwifery Professional Judgement safe staffing RAG Rates
Green - Staffing numbers are as expected on the rota and ward is assessed as being safely staffed taking into consideration workload and patient acuity. Staffing numbers are not as expected
but safe according to current workload.
Amber - Staffing numbers are not as expected and minor adjustments need to be made to bring staffing to a reasonable level given workload and acuity or staffing numbers are as expected
but given workload and acuity additional staff are required.
Red - Staffing levels inadequate to cope with current patient needs.
Division
Area
A&E
Medicine
AAU Blue L1
Date
Shift
Professional
Judgement
Rag Rating
18/08/2014
Day
A
Supported by A&E lead nurse and ANP
22/08/2014
Day
A
25/08/2014
Night
A
Supported by A&E lead nurse and ANP
moved staff within the department to mitigate
31/08/2014
Day
A
staff moved around to make areas safe used HCA as 4th member of staff in resus
28/08/2014
Day
A
Band 7 supported the bay
Comments, Mitigation - Actions taken to Ensure safe Staffing Levels
One SN still not filled in by NHSP. Support from G&P L3
AAU Blue L3
10/08/2014
Night
A
AAU Green
L1
30/08/2014
Day
A
31/08/2014
Night
A
01/08/2014
Day
A
01/08/2014
Night
A
Requiring 1:1 special for a mental health patient - escalated A/W approval from senior nursing.
02/08/2014
Day
A
16/08/2014
Day
A
RN down due to SSS. Escalted to senior nurse. RN sent to cover.
1 x registered nurse off sick, shift put out to bank yesterday but has not filled. Band 7 on AAU made aware to support.
24/08/2014
Day
A
1 RN outstanding for night shift. Escalated to on call senior nurse. Datix form recorded.
25/08/2014
Night
A
29/08/2014
Day
A
03/08/2014
Night
A
04/08/2014
Day
A
20/08/2014
Day
A
30/08/2014
Day
A
RN not filled, out to NHSP band 7 to support the area.
02/08/2014
Day
A
05/08/2014
Day
A
LD for RN out on NHSP, but not yet covered. Escalated to senior nurse.
band 7 to help on the ward
09/08/2014
Day
A
13/08/2014
Night
A
AAU Red
Suite
AAU Triage
AAU Triage
Bluebell
Page 43 of 52
RN Shift out to NHSP but not filled. Band 7 in aau will support the area.
2 RN down tonight in green out to NHSP. Will look at staff with in aau level 1 and make it safe. 1 shift filled
Requiring 1:1 special for a mental health patient - escalated A/W approval from senior nursing.
1 rn down as agency nurse did not attend. Bed manager and senior nurse aware.
1 HCA off sick. Matron aware. Unable to get cover. Ward was safe.
Supported from Green L1
SSR will be working in the number this morning
1 RN +HCA needed to special patient in SR13. Band 7 supervisory supporting clinically
Down RN sick. Escalated to senior nurse
Long day agency RN, name on system but has not attended. HCA has rang in sick early hours. Will call NHSP to follow up RN. RN redepoyed to area to work the LD.
Winyard
Acute Stroke
Unit
Aldenham
Cassio
CCU
Croxley
Gade
Heronsgate
Sarratt
Surgery
De La Mare
Page 44 of 52
Langley
06/08/2014
09/08/2014
Night
Day
A
A
10/08/2014
Day
A
11/08/2014
23/08/2014
Day
Day
A
A
30/08/2014
Day
A
30/08/2014
Night
A
07/08/2014
Day
A
1 trained and 1 hca sick. No cover from other areas available. Escalated to matron
11/08/2014
Day
A
Need RN and HCA for the Stroke gym for LD and Night. RN and HCA moved from AAU surge to support surge into gym. Acuity of patients remains high
23/08/2014
Day
A
Escalated to senior nurse on call
23/08/2014
Day
A
Trained nurse awaiting pin number and HCA called in sick 22/08/14 at 21:00. Tried to swap HCA with RN with another ward. Escalated to Senior nurse on call.
27/08/2014
Day
A
30/08/2014
Day
A
17/08/2014
Night
A
23/08/2014
Day
A
24/08/2014
Day
A
01/08/2014
Night
A
03/08/2014
Night
A
09/08/2014
Day
A
09/08/2014
Night
A
13/08/2014
Day
A
15/08/2014
Day
A
23/08/2014
Day
A
26/08/2014
Night
A
30/08/2014
Day
A
10/08/2014
11/08/2014
02/08/2014
02/08/2014
09/08/2014
14/08/2014
Night
Night
Day
Night
Day
Night
A
A
A
A
A
A
30/08/2014
Day
A
16/08/2014
Day
A
Agency RN did not attend. Nurse requested to help from Aldenham ward for short period
one nurse sent to Aldenham ward for a period later returned ward required special for confused patient not available. This decison was made by the senior nurse on call and left the ward
short
Day Made safe by Gade ward to assist where possible.
23/08/2014
Night
A
Escalated to bed management
01/08/2014
Night
A
30/08/2014
Day
A
bank nurse did cancelled. Bed manager informed. Patients divided between RN's to facilitate ratio 1-8
Support from Croxley
02/08/2014
18/08/2014
Day
Day
A
A
10/08/2014
Day
A
Ward manager and on-call manager informed
Beckett closed. We have 12 inpatients and 13 admissions today. Bnad 6 sent home sick. No senior cover. Staffing levels escalated to matron
HCA on duty called in sick- agency trained sent from letchmore to cover morning
29/08/2014
Day
A
Band 7 working clinically for early duty due to trained staff short fall; 2 day one, post operative patients on the ward who would normally have been in ITU - requiring high level of nursing and
monitoring. Late part of the duty will require increased staffing.
x1 band 5 nurse not filled out to agency matron aware.
2 trained and 1 supernumeray. Will escalate to the matron.
Phoned staffs but no one available to work. Informed bed manager today re: staffing number.
x1 band 5 off sick. Will d/w my matron.
x1 band 5 down and special not filled for an aggressive patient. Senior nurse on call authorised A5 but not filled. Band 5 out to agency. Regular staff unable to work.
x1 band 5 down for LD but an extra HCA.
X1 band 5 down for night. Senior nurse on call aware and shifts out to agency.
HDU patients x 3. Escalated to matron who will support clinically where required.
RGN awaiting pin, HCA not booked came for shift . Three patients needing special in HDU. Supported from CCU
Bed manager was made aware as R/N from Agency did not turn up ward ran on 2 R/N and 2 CSW as bed manager found a spare CSW.
Ward R/N went home sick Bed manager and NHSP aware that shift was required not covered ward ran below staffing 2 R/N 2 CSW
Bed manager aware NHSP unable to fill ward ran on 2 R/N 2 CSW below staffing levels. We were down R/N due to sickness
1 trained short on day shift and 1 trained short on night shft, out in the bank but still not filled in. Band 7 in numbers on Early
Band 7 available for support
LD-HCA cover instead of registered nurse
Night- Covered with HCA, Band7 available for support at any time.
nurse redeployed to ASU, band 7 in the numbers
RN out to NHSP. Band 7 available for support.
RN out to NHSP. Band 7 can be contacted for support.
RN short out to NHSP. Band 7 can be contacted for support
RN moved to Aldenham due to lack of staff and replaced with HCA. Band 7 can be contacted for support.
1XRGN SICK NOCTE-NOT COVERED. Cross cover from Sarratt
1 RN NIGHT DUTY OUT TO NHSP/AGENCY cross cover from Sarratt
NO CSW FROM 13.00-16.00HRS. SUPPORT FROM HERONSGATE.
Support from Heronsgate
Bed manager/senior nurse on call aware. Shift is short. Hca offered for swap with rn but nurse in charge managed with staff on duty
Day
Day
A
A
22/08/2014
Day
A
25/08/2014
Night
A
27/08/2014
07/08/2014
28/08/2014
28/08/2014
Day
Night
Day
Night
A
A
A
A
31/08/2014
Night
A
short of RN on late as one RN only on early. Band 7 supporting clinically
Admitted patients unable to increase staffing. Patients on the unit were safe with minor adjustments
Amber due to acuity of the patients at the time. Level 3 x 13 Level 2 x 5. Escalated to on call manager. Ward nurse was provided to help
Amber due to acuity of the patients at the time. Level 3 x 13 Level 2 x 5. Escalated to on call manager. Ward nurse was provided to help
Inadequate staffing levels to cope with current patients/workload. Staff on the shift did manage the patients safely. There was additional pressure as the anaesthetetic team were busy.
Outreach was used to support. Matron informed in the am.
01/08/2014
Day
A
Short MLD. Starfish aware and Senior sister from Safari can cover. A&E will help if needed.
14/08/2014
Day
A
Starfish and A&E will help as required.
29/08/2014
Night
A
x1 night team is on a twilight. Starfish will cover CED in the event of a resus
30/08/2014
Night
A
x1 MLD finishing at 8pm so night are short until 10pm but A&E and Starfish are aware and to support.
19/08/2014
Day
A
20/08/2014
Day
A
Out to agency, not yet filled-support offered from Starfish Ward.
22/08/2014
01/08/2014
Day
Day
A
A
Band 7 included in numbers.
07/08/2014
Day
A
01/08/2014
Day
A
12/08/2014
Day
A
No Supervisory role today. x 6 electives coming in. 5 medical patients. 1 orthopaedic patient. 4 surgical patients.
15/08/2014
Day
A
22/08/2014
Day
A
EU nurse awaiting pin number mitigation working as supernumery untrained
We will be Amber for the late. X2 overseas nurses, 1 with no PIN and the other is on performance management. Band 5 agency nurse on and the outstanding Band 5 is not covered.
Supervisory supporting clinically
23/08/2014
Night
A
1 RGN off sick. Chief nurse aware and has advised not to put the shifts out to bank unless the bed managers are going to use the beds.
26/08/2014
Day
A
x 5 electives to come in. x 14 medical patients. X5 surgical patients. When the early shift RN goes home at 5pm this will only leave 3 RNs on the ward, one of these extremely junior.
Supervisory supporting clinically
27/08/2014
Day
A
x 14 medical patients. X4 surgical patients. Only 3 members of staff on this morning. 2 of these permanent and one agency. One permanent, is very junior overseas nurse. Only 1 HCA and
he is agency & 1 HCA on an early. Band 7 is in the numbers in the afternoon. X5 electives to come in, only 1 bed available. Concerns about staffs ability to maintain patient care at a high
level due to activity and skill mix.
01/08/2014
Day
A
1 x HCA short shift out to nhsp, will redeploy staff
09/08/2014
Night
A
23/08/2014
Day
A
1 x HCA short will redeploy and cover from another area
Informed agencies of vacancies. Staff moved around to accomadate workload leaving 1 RM short on d/s - but safe according to current workload
26/08/2014
Day
A
1 rm down on early shift. Band 7 on management day covering this on d/s as d/s busy. Agency rm called no answer
29/08/2014
Night
A
10/08/2014
Night
A
2 x RM short on night shift . Have gone out to agency- expected to be filled by the night. Redeployed within division
HCA short will redeploy HCA from another area if needed
09/08/2014
Night
A
1 x HCA short will redeploy and cover from another area
23/08/2014
Day
A
x 1 RM down as staff moved to accommodate workload in other areas. Staffing level safe according to current workload
27/08/2014
Day
A
Redeployed all midwife's x3 to help on delivery at 21:00hrs activity high. 2 PN transferd to postnatal ward.
01/08/2014
10/08/2014
Night
Night
A
A
I x nursery nurse short on night duty , shift out to nhsp. Will redeploy from other areas
23/08/2014
Day
A
26/08/2014
Day
A
16/08/2014
18/08/2014
Letchmore
Ridge
Paediatrics
Womens & Childrens
Combined
ITU
CED
Safari Day
Unit
Gynaecology
Starfish
Elizabeth
Maternity
Delivery
Suite
Victoria
ABC
Katherine
Knutsford
Page 45 of 52
1x RN & 1x HCA offsick. RN for ESAU moved to Letchmore to cover shortage. Only 1 RN can do I.V.s for Letchmore & ESAU.
2 trained nurses sick, 1 RN shift uncovered by nhsp, 2 trained nurses moved to cover. No supervisory today
One HCA off sick today, ward acuity is high, bed manager and surgical matron made aware will continue to assess.
One RN short on Letchmore, HCA pulled from ESAU, Ward Acuity currently high with confused clients. Situlation to be discussed with oncall manager.
Agency nurse was booked but was cancelled by agency yesterday afternoon. Student nurse to work early shift and Clinical Facilitator to assist with preop assessments.
Nhsp unable to provide cover, senior management team aware and are able to assist where needed.
One qualified nurse short of planned level of staffing. Ward full with high level of acuity in the morning. Discharges expected during the day. Risk mitigated by clinical facilitator covering
ward and medical / surgical teams providing swift review.
Covered for morning but late will leave only x3 Band 5 as NHSP nurse called in at 07.10. Still out to try and cover for the late. Supervisory supporting clinically
HCA short will redeploy HCA from another area if needed
x 1 RM down on late shift - agencies informed. Also x 1 HCA down on late shift as bank cancelled. Will redeploy staff from other areas if HCA shift not filled
agency rm called in sick ar 0600. no patients currently on ward. HCA moved to triage as HCA off sick on triage. Agency has found a rm for day shift starting around 10.00 - this rm will be
required on d/s unless patients attend for knutsford
Appendix 4
Current nurse to bed, staff to bed and trained to untrained skill mix. All ratios are rounded to
the nearest whole number.
The nurse to patient ratio indicates the number of registered nurses required to care for a
specific number of patients for example a 1:7 ratio means one registered nurse is required
for every 7 patients. This ratio may vary according to the specialty for example critical care
patients require one nurse to one patient (1:1)
The staff to bed ratio indicates the total number of registered nurses and health care support
workers required to care for a specific number of patients in beds. The staff to bed ratio will
vary according to the type of ward, acuity and dependency of patient’s, location and ward
layout, activity and patient flow.
The overall nurse to bed and staff to bed ratio does not take into account where staffing is
reduced for example when staff take breaks, usually 1 hour of time per person on each long
day and night shift. The actual nurse and staff to bed available to give care to patients during
this time is less.
WARDS
Current Nurse to Current Nurse to
patient ratio days patient ratio nights
Current Staff to Current staff to Current
bed days
bed nights
skill mix
Ridge
1:7
1:10
1:4
1:6
60/40
Langley
1:6
1:8
1:4
1:5
67/33
Cleves
1:7
1:7
1:4
1:6
62/38
Flaunden
1:7
1:7
1:4
1:6
68/32
Letchmore
1:7
1:7
1:4
1:6
68/32
Elizabeth
1:7
1:9
1:5
1:6
67/33
Beckett/ De-la-Mare
1:7
1:9
1:5
1:7
68/32
AAU Green L1
1:5
1:5
1:3
1:3
62/38
AAU Yellow L1
1:5
1:5
1:3
1:3
62/38
AAU Blue L1
1:5
1:5
1:3
1:3
62/38
Green & Purple L3
1:7
1:7
1:3
1:5
61/39
Yellow L3
1:7
1:7
1:3
1:4
68/32
Blue L3 isolation
1:3
1:3
1:2
1:2
Blue L3
1:6
1:6
1:3
1:4
Bluebell
1:4
1:4
1:2
1:2
51/49
Winyard
1:6
1:6
1:4
1:4
62/38
Red (Surge)
1:6
1:6
1:4
1:5
68/32
Croxley
1:7
1:7
1:4
1:4
56/44
Sarratt
1:7
1:7
1:4
1:5
58/48
Gade
1:6
1:6
1:3
1:4
68/32
Heronsgate
1:7
1:7
1:4
1:5
66/34
Cassio
1:7
1:7
1:4
1:5
68/32
Dick Edmunds
1:5
1:5
1:3
1:3
68/32
Aldenham + HDU
1: 5
1:5
1:3
1:4
76/34
CCU
1:3
1:3
1:2
1:3
90/10
Page 46 of 52
62/38
Appendix 5
Summary of outputs from all review models.
Funded
establishment
SNCT
benchmark
Professional
judgment
Dependency
benchmark
Dependency
tool
variance
compared to
SNCT
Ridge
31.47
32.28
31.47
31.70
-0.58
31.82
-0.35
Langley
20.31
16.74
18.28
20.10
3.36
18.37
1.94
Cleves
26.10
29.23
28.76
24.00
-5.23
27.33
-1.23
Flaunden
31.26
30.08
31.32
35.10
5.02
32.17
-0.91
Letchmore
23.46
23.68
23.54
27.60
3.92
24.94
-1.48
Croxley
38.30
35.37
38.30
28.90
-6.47
34.19
4.11
Sarratt
46.23
51.01
46.23
37.20
-13.81
44.81
1.42
Aldenham
41.87
29.60
44.40
38.96
9.36
37.65
4.22
Gade
23.54
20.88
23.54
23.60
2.72
22.67
0.87
Heronsgate
24.39
25.42
26.10
22.20
-3.22
24.57
-0.18
CCU
23.40
11.38
23.40
28.71
17.33
21.16
2.24
Cassio
23.53
23.23
23.53
22.20
-1.03
22.99
0.54
Dick Edmunds
53.93
45.02
53.93
61.70
16.68
53.55
0.38
Bluebell
41.80
23.04
41.80
41.80
18.76
35.55
6.25
Winyard
26.18
21.85
26.18
20.00
-1.85
22.68
3.50
AAU Green L1
26.14
22.08
26.14
24.60
2.52
24.27
1.87
AAU Yellow L1
26.14
20.91
26.14
24.60
3.69
23.88
2.26
AAU Blue L1
26.14
20.22
26.14
24.60
4.38
23.65
2.49
AAU Green &
Purple L3
38.48
30.33
38.48
30.00
-0.33
32.94
5.54
AAU Yellow L3
23.55
17.32
23.55
16.70
-0.62
19.19
4.36
AAU Blue L3
33.96
21.74
33.96
22.10
0.36
25.93
8.03
Elizabeth
30.30
27.29
28.72
31.00
3.71
29.00
1.30
Red (Surge)
23.50
18.95
23.50
20.00
1.05
20.82
2.68
Beckett & De la
Mare
33.64
32.70
33.64
34.70
2.00
33.68
-0.04
Total
737.62
630.36
741.05
692.07
61.72
687.83
49.79
107.26
-3.43
45.55
Variance
Page 47 of 52
Triangulation
benchmark
Triangulation
variance vs.
funded
49.79
Appendix 6
Strengths and limitations of acuity and dependency tools.
As per recommendations, multiple tools were utilised during the review in order to provide
balanced assurance. The table below lists the strengths and limitations of each method.
Safer Nursing Care Tool
Professional judgment
Dependency tool
SNCT does not provide
recommendations at shift level,
however tool is designed to
make provision for sufficient staff
per shift
Professional judgment should
take account of total
establishment needed to meet
required qualified staff per shift
Dependency tool does not
provide recommendations at
shift level, however tool is
designed to make provision for
sufficient staff per shift
SNCT provides recommendation
at total establishment level only
does not take into account
skillmix
Professional judgment should
take account of skill mix split
Dependency tool splits
establishment recommendation
by qualified and unqualified
SNCT has been revised to reflect
patient turnover, and AAU
specific metrics developed.
However generic factors still
based on assumptions of
turnover
Provides qualitative assessment
of staffing requirement to
manage average daily turnover
National average staffing per
ward, grouped & benchmarked
at specialty level
Point in time assessment of
acuity & dependency; accuracy
can be enhanced by repeating
for exercise for multiple weeks at
regular intervals in the year
Implicitly incorporates average
activity/ trends, however this is
not quantified or made explicit
Implicitly incorporates average
activity/ trends, however this is
not quantified or made explicit
Captures actual acuity and
dependency of patients based on
critical care scorings, subject to
user interpretation
Provides qualitative assessment
of staffing requirement to
manage average acutiy and
dependency
Based on assumed acuity and
dependency of patients
according to bed base
Provides point in time
assessment of actual bed
occupancy which may not be
representative across the day.
Does not take account of actual
patient turnover however generic
factors build in assumptions of
turnover
Provides qualitative assessment
of staffing requirement to
manage average bed occupancy
The model has the capacity to
factor in actual bed capacity
which is fairly robust if based on
accurate data
Input data subject to
interpretation, however validation
by senior nurses took place to
improve accuracy of capture
Subject to ward manager
interpretation, validation from
senior nursing team to improve
accuracy
Establishment based on
benchmarked metrics, subject
to user interpretation of ward
type
Qualified staff per shift
NICE guidelines state that
each registered nurse
should care for no more
than 8 patients per day or
there is a risk of increased
harm to patients
Registered to
Unregistered skill mix
RCN guidelines
recommend Registered to
Unregistered ratios
between 65:35 and 70:30
and 50/50 – 65-35 in older
people
Patient throughput /
turnover
Representative of
fluctuations throughout
day/ week/ year
Actual patient acuity and
dependency
Actual bed occupancy
Standardised,
quantitative approach
Page 48 of 52
Appendix 7
SNCT methodology, patient classifications, multipliers and definitions








Adult inpatient
SNCT
WHHT
multiplier multiplier*
Score
Level 0
0.99
Level 1a
Level 1b
Level 2
Level 3
The SNCT captured the acuity and dependency of bedded inpatients at 3pm on weekdays
between June 23rd and July 11th 2014.
Ward managers allocated each patient a score between zero and three based on Critical Care
patient definitions.
Scores were reviewed, validated and challenged daily by a senior nurse.
Scores were multiplied by the factors outlined in SNCT guidelines the sum of the factors provided
a recommended daily staffing establishment, reflecting qualified and unqualified nursing staff. An
average score was calculated based on the three week period.
Specific recommended multipliers were used for AAU to reflect patient turnover.
All Multipliers were adjusted to reflect the 21.6% uplift applied at WHHT.
An assumption of 100% occupancy was incorporated into the analysis; blanks were allocated a
score of zero up to full occupancy and escalation capacity was excluded (i.e. 3 bedded ASU
gym).
Supernumerary Band 7s were excluded from the SNCT recommendation and funded baseline.
1.39
1.72
1.97
5.96
Page 49 of 52
0.99
1.39
1.71
1.96
5.94
AAU
SNCT
WHHT
multiplier multiplier*
1.27
1.66
2.08
2.26
5.96
Definition
Example care requirements
1.27
Patient requires
hospitalisation.
Needs met by
provision of normal
ward cares
Elective admission; Underlying medical
condition requiring on-going treatment;
Regular observations (2 - 4 hourly);
ECG monitoring; Fluid management;
Oxygen therapy < 35%; Single chest
drain, Confused patient not at risk;
Requires assistance of one person to
mobilise
1.65
Acutely ill patients
requiring
intervention of
those who are
unstable with a
greater potential to
deteriorate
Increased level of observations and
therapeutic intervention; Oxygen
therapy > 35%; Post 24 hours following
insertion of tracheostomy, central lines,
epidural or multiple chest or extra
ventricular drains
2.07
Patients who are in
a stable condition
but are dependent
on nursing care to
meet most or all
activities of daily
living
Complex wound management requiring
more than one nurse or taking more
than one hour; Mobility or repositioning
difficulties requiring more than two
people; Complex Intravenous Drug
Regimes; Patients on EoL pathway;
Confused patients at risk or requiring
constant supervision
2.25
May be managed
within clearly
identified
designated beds,
resources with
required expertise
and staffing level,
or dedicated L2
facility
Deteriorating/ compromised single
organ system; Patients requiring noninvasive ventilation/ respiratory support;
CPAP/ BiPAP; Greater than 50%
oxygen; Drug infusions requiring
monitoring; CNS depression of airway
and protective reflexes
Patients needing
advanced
respiratory support
and/ or therapeutic
support of multiple
organs
Monitoring and supportive therapy for
compromised/ collapse of two or more
organ/ systems; Respiratory or CNS
depression/ compromise requires
mechanical/ invasive ventilation;
Invasive monitoring, vasoactive drugs,
treatment of
hypovolaemia/haemorrhage/ sepsis or
neuro protection
5.94
Appendix 8
Patient Dependency tool UK benchmarks .
Example of nurse staffing from best practice wards in the UK and is based on Activities of daily living dependency data – This method considers ward staff per
occupied bed and benchmarks current staffing from a national database and covers 28 specialist wards. This result may not be reflective of the real
dependency activity on a given ward.
Medical and Medical Speciality Wards
Wards
Jul-13
185
Enter the occupied beds below in Column H, Row 2.
Optional, you can adjust the time-out (sickness-absence) value in cell H7. N.B. 21% is entered as 0.21
How many days is your ward open (enter your answer here)?
7
days
How many hours is your ward open (enter your answer here)?
24
hours
The values in C11 to C18 are the recommended staffing for the ward.
I11 to I18 is the average actual FTEs by grade divided by the number of occupied beds. You can calculate your own in the same way.
C20 to C23 recommends 'safe cover' staffing when workload falls significantly.
If you think you've made a mistake then do not 'save' but reload the template and start again.
Highlight the range you want to print before printing the results.
Ward Name:
Row
1
2
3
4
5
6
7
8
9
10
Heronsgate
Column B
11
Page 50 of 52
C
D
Dep.1
3.1
16%
2.1
1.0
3
Dep.2
8.8
44%
5
2
19
Grade Mix (Band)
FTE's
Best Practice
Total
22.2
100%
Patients
Patient Mix
Hourly mins.
Ratios
Workload index
Time out
Breaks
E
Dep.3
5.7
28%
8.5
4.1
23
F
Dep.4
2.4
12%
13.4
6.4
15
Competenc
e
101%
Per Bed
1.11
G
Spcld
0%
H
Total
20.0
100%
6139.5
61
21.6%
12.7%
Page 51 of 52
Appendix 9
Cardiac Care Unit and Level 3 AAU - Current configuration and funded establishment
Funded
No Beds establishment
Ward area
Current Nurse Current Nurse Current
to bed days
to bed night
skillmix
Cardiac care unit
11
24.60
1:3
1:3
90/10
Green purple
27
39.68
1:7
1:7
61/39
1:5
1:5
68/32
1:6
1:6
1:3
1:3
Yellow L3
27
59.90
Blue L3
Blue Isolation Suite
6
Totals
71
62/38
124.18
Cardiac Care Unit and Level 3 AAU - Proposed re-configuration and establishment
Ward area
Beds
Proposed
Establishment
AAU L3 - Cardiac care unit
24
Yellow /Blue L3
30
Blue Isolation Suite
6
* 11 medical beds
11
19.49
Totals
71
118.50
Proposed
Nurse to bed
days
37.76
61.25
Proposed
Nurse to bed
night
1:4
1:5
1:6
1:6
1:3
1:3
1:6
1:6
Proposed
skillmix
79/21
62/38
55/45
* Previously the Cardiac care unit beds – It is proposed that the 11 medical beds will be managed by
the Acute Stroke Unit Nursing team.
Financial Information – All identified posts have been costed by finance at mid-point of pay scale
Total Savings
Page 52 of 52
WTE
Cost at mid-point for 12
months
Cost for 7 months
5.68
269,488.00
157,201.33