SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Meeting Board of Directors

Date 28 April 2016

Subject Nurse Staffing Report

Enclosure E

Nature of item For information

For approval For decision

Decision required (if any)

The Board is asked to receive and note this report.

General Information

Report Author Fiona Burton, Deputy Director of Nursing Helen Lancaster, Director of Nursing

Lead Director Helen Lancaster , Director of Nursing Received or approved by

Meeting Date

Resource Implications

Revenue Capital Workforce Use of Estate Funding Source

Applicable Quality Improvement Priorities

Over 75s Initiative Health Population Home First Service Tertiary Pathways Quality Measures Redesign of Out of

Hospital Services

Nurse Staffing Levels Flow Programme

Freedom of Information

Confidential (Y/N) (if yes, give reasons)

No

Final/draft format

Final

Ownership

Trust

Intended for release to the public

Yes

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South Warwickshire NHS Foundation Trust

Report to Board of Directors – 28 April 2016

Nurse Staffing Report

Executive Opinion This report provides assurance that safe staffing levels are being met in line with national recommendations. Where there are shortfalls in staffing levels compensatory measures are put in place to ensure that safety and quality is not being compromised. Executive Summary This report provides an overview of the actual nurse staffing levels across the inpatient ward areas compared to the planned levels throughout March 2016. This has identified an overall gap of 2%, with 9 wards reporting a gap of over 5%. A further comparison has also been made between days and nights and registered nurses/midwifes and care staff. This analysis has shown there to be a 8% gap in registered nurses on duty during the day and 8% at night. In comparison there is an overstaffing position for clinical support workers in the day of +5% and +13% at night. The Board has been given data from the Safecare healthroster module that identifies the nurse staffing hours required for each ward based on the patient acuity and dependency. This has demonstrated that through March 2016 there were wards with a lower staffing requirement that those planned and vice versa. The number of shifts where the number of qualified nurses per patient has breached the national guidance of 1:8 ratio during the day in acute inpatient wards were 119, which is a decrease from last month. This equates to 8.7% of day time shifts across the acute wards. It has shown that on analysis a reduction in staffing has not affected the quality and safety of patient care. A number of causes for the shortfalls in staffing across the areas were identified and actions have been suggested to address these gaps. Helen Lancaster Director of Nursing

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South Warwickshire NHS Foundation Trust

Report to Board of Directors – 28 April 2016

Nurse Staffing Report

Introduction This report presents the latest nurse staffing across all inpatient wards during March 2016. The purpose of this report is to update the Board in relation to the nurse staffing levels and specifically the gap between the planned staffing levels and the levels that actually occurred; how big the difference is and why, if this difference affected the quality of patient care and how any risks are being mitigated. Summary of Inpatient Nurse Staffing during March 2016 Graph 1 below demonstrates that the overall gap in nurse staffing between the planned and the actual numbers reported on duty across the inpatient wards of the Trust in March 2016 was 2%, this is an improvement from last month.

This 2% gap is made up of wards that had less staff on duty than planned and others that had more staff than planned. Graph 2 below identifies how these gaps and overstaffing numbers differ between the different wards with Avon; Beaumont; Nicholas, Willoughby, Greville, 23 hour, ITU, Campion and Chadwick Wards all having a gap of over 5%. Graph 1

1% 1% 4% 4% 4% 4% 4% 4% 4% 4% 3% 2%

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May Jun Jul

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All staff during both shifts staff levels % Sum of % actual Sum of % gap

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Graph 2

A further comparison has also been made between days and nights and registered nurses/midwifes and care staff. Graphs 3, 4, 5 and 6 below show these differences for the month of March 2016. This information demonstrates that the inpatient wards are understaffed in qualified nursing staff during the day by 8% and unstaffed by 8% at night, but this is being compensated for by overstaffing in care staff by +5% in the daytime and +13% at night. Graph 3

Graph 4

-10%

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Avon

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All staff during both shifts Staff levels % by all Wards Sum of % actual Sum of % gap

92%

8%

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Registered Nurse / Midwife Staffing Levels in the Day

Sum of Registered % Gap Day

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92%

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Registered Nurse / Midwife Staffing Levels in the Night Sum of Registered % gap Night

10% Under

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Graph 5

Graph 6

Safecare The Safecare healthroster module is now being used across all acute inpatient wards with the exception of Fairfax/Oken Ward. This enables each ward to calculate the number of staffing hours they require each shift according to the actual dependency and acuity of their patients, and compare this to their planned and actual staffing numbers. This information is being used to support the most safe and efficient use and movement of resources on a shift by shift basis based on acuity of patients rather than just the number of patients. The Safecare information for March 2016 is displayed in the graph below. The red rostered bars are the number of staff actually on duty in hours across the month per ward on the X axis; the planned hours are the agreed staffing hours in the wards ASL; the required care is the hours of staff time required according to the patient acuity across the month of March 2016.

105%

-5%

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Care Staff Levels in the Day Sum of Care % Actual Day Sum of Care % gap Day

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113%

-13%

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Care Staff Levels in the Night Sum of Care % Actual Night Sum of Care % gap Night

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01000200030004000500060007000

Avon

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March 2016 Rostered Care Required Care Planned Hours

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As you can see from the graph above the wards that have the most significant gap between the acuity of their patients and their planned and actual hours of staffing are Willoughby, Victoria, Charlecote and Castle Wards. The Director of Nursing has requested that the Heads of Nursing and Matrons monitor this position further through the month of April 2016 and a professional recommendation will be made in May 2016 about whether resources need to be changed or moved on a more permanent basis between wards now that the Safecare module appears to be embedded The wards that have more planned and actual than their need according to the acuity of their patients are Greville and Beaumont Wards. Greville Ward is sometimes overstaffed for the number and acuity of their patients because of ring fenced orthopaedic beds on Greville Ward and the need for two qualified nurses to manage the ward as a minimum even when they have very low patient numbers. However they do often flex when the short stay surgical is full. The number of shifts where the number of qualified nurses per patient has breached the national guidance of 1:8 ratio during the day in acute inpatient wards was 119 in March 2016 compared to 130 in February 2016. This equates to 8.7% of all daytime shifts across the 22 wards. This is a decrease compared to previous months. These included 29 on Willoughby Ward; 20 on Avon Ward; 15 on Malins Ward; 12 on Victoria Ward; 11 on Nicholas Ward; 8 on Thomas Ward; 7 on Farries and Castle Wards; 6 on Mary Ward and 4 on Squire Ward. These occasions will have been escalated at the time to the daily bed meeting and the workload prioritised to keep patients safe. This represents a lower number of breaches across a smaller number of inpatient wards than previous months. It is hoped that this will be an improving picture due to the increased recruitment activity over the last few months.eg overseas recruitment, newly qualified nurses who now have their PIN number. During March 2016 there were 31 incidents reporting inadequate staffing levels compared to 19 in February 2016. These have been categorised as either a breach in 1:8 registered nurses during the day; a breach of 1:10 registered nurses at night and if these have had any impact on the patients. Graphs 7 and 8 below demonstrate the wards and departments where staffing incidents have been reported and the number of times patient care has reportedly been affected. As you can see Campion, Chadwick, ITU and Malins Wards reported the most incidents. Staff are often moved from wards where there is a greater ratio of nurses per patient when there are shortages. Decisions to move staff are always difficult to make when the staffing resource is depleted. The senior nurse bleep holder uses risk assessment tools to support such decision making to ensure staff are moved only when it is necessary to do so and where the patient acuity and number warrant it.

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Graph 7

Graph 8

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Staffing Levels by ward/site March 2016

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Less than 1Qualified nurseto 8 patients -

During Day

Less than 1Qualified nurseto 10 patients -

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Intentionalrounding processnot implemented

to care plan

Unplannedomission in

providing patientmedication

No impact topatient care

Community -Staff Shortage

Staffing Levels by Sub category March 2016

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Analysis Analysis has been undertaken to better understand the effects the reported shortage of staff is having on the quality and safety of patient care, the reasons for these and the actions that are required to reduce them. Effects on Quality and Safety Appendix 1 provides an overview of the Nurse Care Indicators (NCIs), Safety Thermometer and Friends and Family Test (FFT) results and the number of incidents reported from the inpatient wards that had an overall gap of over 5% nurse staffing during March 2016 (23 hours, Avon, Beaumont, Nicholas, Campion, Chadwick. ITU, Greville and Willoughby Wards). From this information the Board can see that all of these wards have maintained their NCIs, FFT, clinical incident numbers and Safety Thermometer results at acceptable levels during March 2016, with the exception of Campion and Nicholas Wards Safety Thermometer. Nicholas Ward scored significantly below the national requirement of 95% at 85.7%, whilst Campion Ward was 94.7% again below the national target. When these results have been analysed the Safety Thermometer results on Nicholas Ward resulted from 1 fall and 1 old pressure ulcer. Campion Ward’s Safety Thermometer whilst meeting the National target did not meet the Trust’s target of 96% due to 1 fall. Nursing and Agency Rules- Ceiling for Nursing and Agency Spending The actual nursing agency spend for March 2016 is 3.1% this is a decrease from the previous month which was 4.5%. The cumulative spend is 3.1%. this remains below the Trust cap of 4%. The monthly spend on agency has seen a decrease in March 2016 this is due to the increase in the planned versus actual registered staffing numbers, results of the recruitment activity and the planned reduction of annual leave during the Care Quality Commission (CQC) inspection to allow staff time to talk with the inspectors. During March 2016 159 shifts were covered from agencies above the price cap and 8 shifts were covered by off framework agencies. Conclusion In conclusion, the Board of Directors can be assured that, in the main, the nurse staffing levels across the inpatient wards is in line with national recommendations and this is monitored closely and temporary staff deployed when needed. This can be demonstrated by our patient outcome data and patient satisfaction levels which are good. Recommendations

• Continue with daily nurse staffing levels monitoring and escalation of gaps to assure all is done to reduce these.

• Maintain the current recruitment activity and to prioritise those areas with the highest vacancy factor.

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• To support the continued implementation of the safecare e-rostering module to ensure real time, accurate nurse staffing data that can be compared to real time patient demand based on patient acuity and dependency.

• To ensure that MAU works towards full implementation of the safecare module. • Continue to encourage staff to report staffing incidents through the DATIX incident

reporting system. • Continue to explore alternative shift cover provision eg bleep holding duties and

additional shifts from non-ward rostered staff. • Continue to monitor agency spend and usage.

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Appendix 1: Quality and safety results for those wards that had more than 5% gap in their planned and actual staffing numbers during March 2016. Due to some issues within the information system, Greville and Chadwick charts cannot be produced for this month. This should be resolved by next month. Avon Ward FFT- 100%

Beaumont-FFT-96.6%

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Campion Ward FFT 100%

ITU-FFT 100%

12

Nicholas FFT 100%

Willoughby-FFT 96.8%

13

23 hour –FFT 100%

Greville FFT 100%

ST 100%

NCI 99%

Incidents 13

Chadwick Ward FFT 98%

ST 100%

NCI 98%

Incidents 21