Item 11.5 Hard Truths Appendix 6
Actions to Be Taken When the Numbers Of Nurses Or Midwives Per Shift Falls
Short Of The Agreed Roster Template.
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All wards and departments have an agreed funded establishment (AFE) which
identifies the whole time equivalent staff allocated to your ward or department.
The AFE has been agreed by your Head of Nursing (HoN).
All wards and departments have an agreed roster template agreed by the Senior
Sister/Charge Nurse with the Matron and Head of Nursing. This template
identifies the number of staff of each role type that are planned to be on each
shift through the week on your ward.
The Trust requirement is that on in-patient ward areas a minimum of three staff
should be rostered for each shift and that two of these should be registered staff
unless otherwise agreed by the Head of Nursing.
All wards and departments have a temporary staffing cascade agreed by the
Head of Nursing.
This guidance describes the actions that should be taken if the number of staff on
an individual shift falls below your wards agreed roster template or the Trusts
minimum requirement for in-patient wards.
Short fall identified prior to roster sign off or short fall identified prior to the
day of the shift but after roster sign off :
The Senior Sister / Charge Nurse or nominated deputy should:

Attempt to provide cover for the shift through reallocation and redistribution of
resource from within the ward or department team
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In discussion with the Matron & HoN (in hours), CSM (out of hours) determine if
cover is available from elsewhere within the CSU

Attempt to provide cover through
o
o
o
o
o
Part time ward staff undertaking additional hours
Full time ward staff undertaking an NHSP shift
Booking a ‘bank only’ NHSP worker
Full time staff undertaking an overtime shift
Ask the HoN / Matron (in hours) to release the ‘golden key’: the number of
shifts this is required for needs to be agreed
Shortfall occurs on the day of the shift :
The Senior Sister / Charge Nurse or Nurse in Charge of the shift should:

Attempt to provide cover for the shift through reallocation and redistribution of
resource from within the ward or department team

In discussion with the Matron & HoN (in hours), CSM (out of hours) determine if
cover is available from elsewhere within the CSU

Attempt to provide through:
o
o
o
o
o
Part time ward staff undertaking additional hours
Full time ward staff undertaking an NHSP shift
Booking a ‘bank only’ NHSP worker
Full time staff undertaking an overtime shift
Ask the HoN / Matron (in hours) to release the ‘golden key’: the number of
shifts this is required for needs to be agreed

Where cover is provided from another ward or department for a whole shift the
nurse in charge of the donating and receiving wards should make a record on
the duty roster of the name and grade of the donated nurse. For wards that are
e-rostering this should be done via the e-rostering system.
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The Senior Sister / Charge Nurse or Nurse in Charge should ensure that a
record is made on the ward duty roster where a shift remained partly or wholly
uncovered. For wards that are E-rostering this record should be made on the
system.
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Where the shift remains partly or wholly uncovered the Head of Nursing in hours,
and the CSM out of hours, should be informed.
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A Datix Form should be completed if a wholly or partially uncovered shift resulted
o in fewer than three staff being on duty
o or only one registered nurse being on duty
o or if patient safety was compromised as a result of the shortfall in staffing.
It is important on the form to be clear about the nature of the safety
concern and the actions you have taken.

For the wards with partly or wholly uncovered shifts :
In Hours:
o Head of Nursing is to notify Nurse Director - Operations of outstanding
risk and actions taken. Nurse Director - Operations & Head of Nursing to
agree further actions to manage risk
o Nurse Director - Operations to notify Chief Nurse of outstanding risk,
actions taken and to agree mitigating actions.
Out of Hours:
o CSM to notify on-call Head of Nursing and relevant on call manager and
record outstanding risks on the CSM status report for escalation and
review by the Nurse Director - Operations & Chief Nurse on the next
working day
See attached flow chart
Actions to be taken when the numbers of nurses or midwives per shift falls short
of the agreed roster template

The Trust requirement is that on in-patient ward areas a minimum of three staff should be rostered for each shift and
that two of these should be registered staff unless otherwise agreed by the Head of Nursing
Short fall identified prior to roster sign off or short fall
identified prior to the day of the shift but after roster sign
off
Shortfall occurs on the day of the shift
The Senior Sister/Charge Nurse or nominated deputy should:
Attempt to provide cover for the shift through reallocation and redistribution of resource from within the ward or
department team
If this cannot be done:
In discussion with the Matron & HoN (in hours), CSM (out of hours) determine if cover is available from elsewhere within
the CSU
If this cannot be done:





Attempt to provide cover through:
Part time ward staff undertaking additional hours
Full time ward staff undertaking an NHSP shift
Booking a ‘bank only’ NHSP worker
Full time staff undertaking an overtime shift
Ask the HoN / Matron ( in hours), CSM (out of hours) to release the ‘golden key’ : the number of shifts this is
required for needs to be agreed

Ward remained partly or wholly uncovered
The Nurse in Charge should ensure that a
record is made on the ward duty roster where a
shift remained partly or wholly uncovered. For
wards that are on eRostering this record should
be made on the system
Ward wholly covered by another area
Where cover is provided from another ward or department for a whole
or part shift the nurse in charge of the donating and receiving wards
should make a record on the duty roster of the name and grade of the
donated nurse. For wards that are on eRostering this should be done
via the eRoster system.
Head of Nursing to be made aware
A Datix Form should be completed if a wholly or partially
uncovered shift resulted in:
 In fewer than three nurses being on duty
 Or only one registered nurse being on duty
 Or if patient safety was compromised as a result
of the shortfall in staffing
In Hours:
Head of Nursing is to notify Nurse Director - Operations
of outstanding risk, actions taken.
Nurse Director - Operations & Head of Nursing to agree
further actions to manage risk
If this cannot be done:
Out of Hours:
CSM to notify relevant on-call manager and record
outstanding risks on the CSM status report for
escalation and review by the Nurse Director Operations & Chief Nurse on the next working day
Nurse Director - Operations to notify Chief Nurse of
outstanding risk, actions taken and to agree mitigating
actions
Author - Jill Asbury - Head of Nursing, Workforce & Education 14/10/2015 Review Date: 14/10/2016