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AGENDA ITEM 60 2016/17

BOARD OF DIRECTORSDate of Meeting 28 September 2016Title Executive Chief Nurse ReportReport of Sue Smith

Executive Chief NursePrepared by and contact details

Sue SmithExecutive Chief [email protected] Ext 46697

Status of Report Public Private Internal☒ ☐ ☐

Purpose of Report For Decision For Assurance For Information☐ ☐ ☒

Summary To apprise the Board of Directors with relevant updates regarding the contribution of the nursing, midwifery and allied health professional team across the Trust.

This report provides members of the Board with an overview of progress made within the Executive Chief Nurse portfolio. The key areas covered in this report include:

Staffing update Key achievements and messages; corporate nursing,

midwifery and AHP team including:o Volunteering and Engagemento Quality Assurance Accreditation Schemeo Bay Dementia Hubo National Publications

Recommendation

Recommendation The Board of Directors is asked to:1. note the contents of this paper

Links to Corporate objectivesLinks to Strategic and Clinical RisksImpact Delete Yes or No as appropriate Yes No

Quality and Safety XLegal XFinancial XHuman Resources XEquality and Diversity XEngagement and Communication XIf yes, please give additional information

Reports previously considered by

Executive Chief Nurse ReportUniversity Hospitals of Morecambe Bay NHS Foundation TrustBoard of Directors (28 September 2016)

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UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST

Executive Chief Nurse Report

1. Background

This paper aims to provide members of the Board with a summary of key issues, achievements and challenges within the executive chief nurse portfolio of responsibility.

The paper will incorporate an update on nursing and midwifery staffing which describes an update on acuity and staffing management.

An update will be provided to ensure that there is wider awareness of the range and depth of work led by the nursing, midwifery and allied health professional teams.

2. Staffing Update

This staffing update will focus on a) the current staffing position b)utilising SafeCare to proactively monitor and mitigate staffing risk across our hospitals; c) describe the current service pressures and impact on outcomes; d) describe the describe partnership and innovation to in place to reduce risk

a) Monthly Staffing update

Registered Nursing 1399.30 1233.90 1430 165.40 11.82%

Midwives 169.00 138.60 165 30.40 17.99%

Clinical Support Worker 597.10 622.20 748 -25.10 -4.20%

Grand Total 2165.40 1994.70 2343.00 170.70 7.88%

Registered Nursing 1419.60 1256.30 1465 163.30 11.50%

Midwives 169.90 148.20 180 21.70 12.77%

Clinical Support Worker 611.10 629.80 776 -18.70 -3.06%

Grand Total 2200.60 2034.30 2421.00 166.30 7.56%

Jun-15 Staff in Post v Establishment

Nursing Budgeted Establishment WTE

Staff in Post WTE

Staff in Post Headcount

Variance WTE

Vacancy Factor

Jun-16 Staff in Post v Establishment

Nursing Budgeted Establishment WTE

Staff in Post WTE

Staff in Post Headcount

Variance WTE

Vacancy Factor

The table above shows a comparison of Nursing and Midwifery establishments between August 2015 and August 2016. The figures show a favourable improvement in staffing levels over the last 12 months. The budgeted establishment for RN’s has increased by 10.30 WTE and for CSW’s by 14.0 WTE. Staff in Post have increased by 22.4 WTE for RN’s, 9.6 WTE for MW’s and 7.0 WTE for CSW’s.

The head count has increased by 35 for RN’s, 15 for MW’s and 28 for CSW’s.

Although the vacancy factor remains high overall, it showed a significant improvement in September 2016. The paediatric staffing position is improving as staff return from sick leave and maternity leave. Staffing levels on the AMU and ED at the RLI are expected to improve



over the next few weeks as staff take up post. (Further detail can be found in appendix 1 and 2).

b) Utilising SafeCare to proactively monitor and mitigate staffing risk across our hospitals:

In the last Board report, a clear description of how the Trust monitors, manages and provides assurance on staffing levels was provided. This update referred to UHMBT red rules that all inpatient wards must adhere to in order to maintain standards of care that reduce risk of harm and enable staff to provide an appropriate (acuity) level of care; how this is monitored and how staff work flexibly to minimise risk and maintain standards of care and service. Supported by 7-day matron cover; good understanding of acuity and skills in each ward and department, we have been able to deliver mitigations against increasing service pressures and delayed transfers of care.

Training on the use of SafeCare has been rolled out to all senior nurses and the staffing wheels will be introduced for review at the 12noon patient safety/flow meeting in order to ensure that potential gaps are identified in a proactive manner. For example, at 12noon on a Thursday, the morning, afternoon and overnight weekend shifts will be monitored in order to assess where potential pressures and risks will be; where staff can be moved to support optimum use of staffing, skills and available resources and where capacity may need to be flexed in order to maintain safe care across all departments. This resource will support timely and informed decisions to ensure staffing resources are deployed to maximum effect and with minimal disruption. Progress on the impact of this will be monitored through the weekly ECN meeting.

c) Current service pressures and impact on outcomes:

At the time of writing this report, service pressures remain consistently high despite continued partnership working with commissioners and providers to ensure mitigations are in place. The impact of this is system wide, impacting on GP services, community nursing services, social services, voluntary services and mental health services as well as patients. All partners are working to reduce and mitigate impact as possible.The impact on hospital services cannot be seen in isolation, however, it is important to articulate that there are high numbers of patients in acute hospital beds who, if resources and services were available elsewhere, do not need to be cared for in a hospital environment. The number of patients who experience delays in transfer or discharge (currently over 100 patients) due to lack of capacity closer to their homes continues to impact on delivery of service and on patient and staff experience.

Mental health capacity remains a significant pressure nationally and regionally. An example of the impact of the national shortfall in acute mental health capacity can be in see through the experience of a patient who recently required a section 12 placement for acute mental health treatment, waited for 48-hours in the emergency department before they could be moved to a bed that became available outside London. This is not an isolated incident and is indicative of the service provision currently available for people with acute mental health needs. Whilst we are able to deliver acute physical care within 4-hours for most patients with a medical need; many patients with acute mental health needs are waiting in excess of 12-hours.

Bed capacity has recently been running higher than 100% across inpatient areas over recent weeks, with some days up to 128%. Nationally, there is evidence that when bed occupancy increases over 85%; that harm increases significantly. Types of harm that are recognised to



increase include harm from infection; falls; pressure ulcers and medication errors. There is also a recognised impact on patient and staff experience and on numbers of complaints and incident reporting.

Despite the significant pressures on staff and partner agencies, it is testimony to the hard work, care and commitment of staff at all levels and in all areas; that our harms; mortality; complaints and incidents have not seen a significant increase. This demonstrates that the mitigations and efforts made by front line staff and their leaders to mitigate risk and deliver safe services are being achieved. This is being monitored on a day by day basis and where appropriate, difficult decisions, including closure of beds, are made to ensure we run a safe and effective service.

Outcomes are monitored through ENACT and Quality Assurance Committee and not only are we managing to sustain our strong performance across a number of indicators, we are, despite the pressures, managing to continue to slowly reduce harm and poor experience.

Some of these outcomes are demonstrated below:Graph 1; Hospital acquired pressure ulcers 2016

APRILMAY

JUNEJULY

40

32

2627

Hospital Acquired Pressure Ulcers (April-July 2016)

Table 1; pressure ulcer data (July 2016)Pressure Ulcer Classification

Hospital Acquired Community Acquired

Pressure Ulcer (Grade 1) 7 21Pressure Ulcer (Grade 2) 17 40Pressure Ulcer (Grade 3) 0 7Pressure Ulcer (Grade 4) 0 5Unstageable 2 9Deep tissue injury 1 2Total 27 84

d) Partnership and innovation to reduce risk

The Trust is working closely with partner organisations to integrate professional influence and accountability that span traditional provider barriers. Examples of such innovation include; planned secondment of an acute frailty nurse from hospital to Kendal ICC;



potential of appointment to a joint nurse practitioner appointment to work across Millom and FGH; senior nurses for Lancaster and Morecambe GP practices have a seat on ENACT, enabling them to contribute to holistic development of services across the Bay Health footprint.

Partnerships with local care homes continue to develop with a buddying arrangement between UHMBT matrons and care home managers. A buddying arrangement is now in place to provide sharing of best practice and professional support and advice. Specialist nurses from UHMBT have provided support and training in the prevention of Acute Kidney Injury and work is underway to reduce harm from pressure ulcers both in the community and in hospital.

3. Volunteering and Engagement

3.1 The Accessible Information Standard

The Accessible Information Standard came into effect on the 1st August 2016. The standard directs and defines a specific, consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients, service users and carers where those needs relate to a disability, impairment or sensory loss.

It is of particular relevance to individuals who are blind, deaf, deafblind and those who have a learning disability, although it will support anyone with information or communication needs relating to a disability, impairment or sensory loss, for example people who have aphasia or a mental health condition which affects their ability to communicate.

The Equality of Access group have invited Linda Wilson, Volunteer Campaign Co-ordinator from the Royal National Institute of Blind People Cumbria branch to the October meeting to review our compliance towards the Accessible Information standards.

As part of this work the Trust intranet website now has a browsealoud function. This improves access for those with particular disabilities, offering visitors to our website an enhanced experience.

The browsealoud support function can be accessed by clicking on the image to the left within our website. This function will read out loud, adjust the size of the font and make it easier to read for those with poor sight. It will also offer website translation in multiple languages.

3.2 Partnerships with our voluntary organisations

Our volunteers continue to support the trust in many ways; I am pleased to confirm that the North West Blood Bikes have been successful in their national lottery award. 4911 television viewers voted for our partner volunteer organisation who; as a result have received £3,000 award towards the cost of their blue light motorbike. We now have two volunteer-led blue light bikes positioned within our trust; one at Furness General Hospital and the other at Westmorland General Hospital.

3.3 Furness General Hospital Radio

Entertainment is provided by two hospital radio stations, Radio Lonsdale at Furness General Hospital and the Bay Trust radio for Westmorland General Hospital and Royal Lancaster



Infirmary. Social interaction via hospital radio comes from providing listeners with a virtual friend, and through face to face interaction with volunteers from the station to the bed side.

We know that hospital radio helps create a positive sense of belonging by familiarising patients with the hospital and allowing them to maintain a connection with their lives and people outside.

Our radio stations have the potential to increase awareness of health and wellbeing by delivering information and advice in an appropriate and sensitive way and therefore I would encourage anyone to contact [email protected] with suitable radio content material.

I am pleased to confirm, The Big Lottery awards have awarded £7,367 to our Radio Lonsdale volunteers for the purchase of new audio equipment. This equipment will bring our Radio Lonsdale stations outside broadcast kit up to date and allow two way communications from almost any remote venue back to the hospital radio station.

3.4 Community engagement – Organ Donation

Every year, hundreds of lives are saved with the help of donated organs but with the number of registered organ donors in the UK falling for the first time in over a decade and a growing

transplant list, UHMBT continue to work in partnership with a number of community groups to promote the importance and life changing benefits of becoming an organ donor.

To help spread the word, volunteers from the Trust and the Kendal Organ Donor town team hosted a number of information sessions as part of the national organ donation week during the 5th to 11th September 2016.

3.5 Patient and Public Involvement Strategy.

We know that it is really important to listen to our patients and citizens when making improvements to our services. We encourage feedback from our patients, relatives and visitors, both positive and negative, as it provides an opportunity for the Trust to review services and make any appropriate changes and meet patients’ needs.

A number of our stakeholders attended the annual members meeting on the 15th September 2016 at Lancaster Town Hall. Here we publically launched our Patient, Public Involvement Strategy.

4. Quality Assurance Accreditation Scheme (QAAS)

As part of the UHMBT Quality Improvement Plan 2014–2017; the Quality Assurance Framework was designed to provide an evidence base and assurance that staff are delivering high quality care. The assurance process highlights what works well and identifies where further improvements are required.

The structured framework is aligned the Trusts Vision and Values and provides both internal and external assurance. Wards are bale to apply for ‘exemplar’ status once they have achieved a rating of green over 3 consecutive occasions, which will take a minimum period


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of two years of sustained high standards across hundreds of measures. Since its launch in 2016;

23 areas have commenced the QAAS process to achieve exemplar status. 40 visits and revisits have taken place 13 areas have achieved green status and some areas have achieved green

on two consecutive occasions. We expect our first applications for exemplar to come early in 2017.

5. The Bay Dementia Hub

Friday 6th September marked the opening of The Bay Dementia Hub. There were over 100 members of the public attended and the launch was a great success. Professionals included social services, Alzheimer’s Society, Age UK, solicitors, Benefits Advisor, county councillors, Carers Point, Admiral Nurse and many more.

St Johns Hospice offered free refreshments and volunteers to help serve them; there was also a welcome team of student nurses from University of Cumbria, Lancaster University Students and the Care of the elderly team at UHMBT. We believe that this collaborative approach with partner organisations supports the overall wellbeing of our population and reduces the risk of people who need support with dementia from feeling isolated.

6. National Publications

6.1 Learning Disabilities Core Skills Education and Training Framework.

http://www.skillsforhealth.org.uk/images/resource-section/projects/learning-disabilities/Learning-Disabilities-CSTF.pdf

Children, young people and adults with a learning disability (LD) and/or autism have the right to the same opportunities as anyone else to develop and maintain relationships, and get the support they need to live healthy, safe and rewarding lives. Department of Health figures suggest that about 1.5 million people (around 2.5 per cent of the UK population) in the UK have a learning disability. The prevalence of LD in the general population is expected to grow overall by over ten per cent by 2020.

The Independent Inquiry chaired by Sir Jonathan Michael following publication of the Mencap report (Death by Indifference), provided evidence that people with LD have higher levels of unmet need and receive less effective treatment, despite the fact that the Disability Discrimination Act and Mental Capacity Act set out a clear legal framework for the delivery of equal treatment.

The services and support commissioned for people with a LD are shaped by key government policies and strategies over the last 15-years and these provide an emphasis on a number of important choices including improving opportunities for people with LD to make an informed choice about how they live; addressing social exclusion; increasing the number of people with LD in paid employment; improving support for people with complex needs; improving healthcare outcomes; and improving support for family carers. In addition to those providing health and social care to people (children, young people and adults) with learning





disabilities, others who come into contact with them and their families and carers need to have an awareness and understanding of their specific needs and those of their families and carers.

Commissioned and funded by the Department of Health the development of the framework was led by Skills for Health, Health Education England and Skills for Care in collaboration with a number of key stakeholders and experts in learning disability (LD) care.

The training framework sets out the essential skills and knowledge necessary for all staff involved in caring for people with LD, enabling organisations to identify key skills and knowledge for roles and teams; plan and design content for education and training; commission education and training; conduct training needs analysis; support performance management processes and assessment of competence

The framework is aimed at employers, their employees, educational commissioners and organisations that train students and staff who will be employed in the range of health and care settings.

The core skills and knowledge described in the framework are defined across 3 tiers:

Tier Core skills and knowledgeTier 1

knowledge for roles that require general awareness of learning disabilities

Tier 2

knowledge and skills for roles that will have some regular contact with people (children,young people and adults) with a learning disability

Tier 3

knowledge and skills for those providing care and support for people (children, youngpeople and adults) with a learning disability

The framework describes core skills and knowledge i.e. that which is common and transferable across different types of service provision.

The Trust will review the framework through ENACT, which includes membership from HEE and Regional Professional bodies in order to make recommendations to workforce and quality assurance committees in relation to the next steps for integrating the core skills and learning into everyday practice across the Trust.

6.2 Five Year Forward View for Mental Health

https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf

This national strategy, which covers care and support for all ages, was published in February 2016 and signifies the first time there has been a strategic approach to improving mental

health outcomes across the health and care system, in partnership with the health arm’s length bodies. One in four adults experiences a mental health problem. Poor mental health can affect anyone of any age.





In July 2016, NHS England published an Implementation Plan to set out the actions required to deliver the Five Year Forward View for Mental Health. The Implementation Plan brings together all the health delivery partners to ensure there is cross-system working to meet the recommendations made by the Taskforce.

The strategy was the product of wide ranging engagement with people with personal experience of mental health issues, families, carers and professionals as well as the review of clinical and economic evidence. Over 20,000 people gave their views which demonstrate that people are passionate about improving mental health care and support across the NHS. The findings from that engagement work were included in a report published in September 2015.

Improvements in access to high quality services, choice of interventions, integrated physical and mental health care, prevention initiatives, funding and challenging stigma were people’s top priorities as to how the system needs to change by 2020. This feedback directly shaped the Five Year Forward View for Mental Health.

The report sets out three things to do to better support people with mental health problems in the future. These are:

1) Access:a. People who are really unwell or having a serious mental health problem

should be able to get careb. Hospitals should give emergency mental health care to people who need it 24

hours a day and 7 days a week.c. People should be able to get care as close to home as possible.

2) Bringing mental health care and physical healthcare togethera. Pregnant women and new mums should get mental health care at the same

time as physical health care.b. People with serious mental health problems should have their physical health

checked through annual health checks and should get help with things like giving up smoking, if they want to

c. People with long term physical health conditions should get help for any mental health problems they have, like depression and anxiety.

3) Promoting good mental health and stopping people from having mental health problems

a. We need to understand who is at risk of having mental health problems.b. Care in the NHS should focus on stopping people from having mental health

problems and meeting needs early instead of waiting until people get worse.c. Young people and children should get the support they need wherever they

get care.d. People with mental health problems should get help to find or stay in work.e. The NHS should work with Government departments that offer housing and

social care so they can work together to look after all of the things that have an effect on mental health.

f. People with mental health problems should get better support to stop them from going into the criminal justice system, or should get more help if they are already in it.



The government have committed to invest significant funds into improving the mental health care capacity and capability across the country in order to address the shortfalls that have been identified in provision of mental health care at a national and regional level.

Increasing numbers of patients across the Bay are presenting to Trust emergency departments with acute mental health needs (see section 2b); this picture is reflected across the country. Whilst all service providers work hard to ensure the specialist needs of patients with mental health needs are met as effectively and efficiently as possible, their care is not as timely or effective as any of us would like to see. This is not a fault of any of the stakeholders/partners involved; but a wider reflection of the lack of investment in this area of care over past years. The Trust welcomes the commitment described in the Five Year Forward View and is looking forward to supporting ongoing development of a holistic approach to mental health care across the Morecambe Bay healthcare footprint.

7. Achieving Excellence

7.1 DePuy National Visitation Centre

Tw RLI surgeons, Mr. Patel and Mr. Herlekar have been asked by DePuy for UHMBT to become a National Visitation Centre for Revision Arthroplasty. On-site visitation is designed to provide the opportunity to meet experienced surgeons in either a one-on-one setting or in a small group. Participants observe live surgery and discuss surgical technique, indications, clinical results & process. This smaller group option may be a mix of presentations, case reviews, instrumentation, treatment therapies, and other learning methods.

This will make us the second DePuy visitation centre in the country and the third DePuy visitation centre in Europe. A huge amount of work goes into each and every one of these cases from the team of regular anaesthetists Dr Boothroyd and Dr Baxter, the orthopaedic theatre team and the recovery team. This is a significant achievement for our Trust; well done to all those individuals involved. 7.2 E-development

National Care Certificate (NCC)

Following an initial pilot by the UHMBT vocational training team with a group of apprentice clinical support workers, it was evident following their feedback that there were challenges with the paper process of the care certificate. A team was pulled together comprising of various staff with the skills to develop an electronic NCC Tool within our Learning and Development Programme (TMS). The team have linked in with LiA to support the implementation and sustainability of the certificate, and have received positive feedback from staff in ward and department areas. A trial of the electronic version is hoped to take place within the next month to ensure that issues are resolved prior to initial roll out for clinical staff bands 2-4. Nurse Revalidation Tool

The implementation of the nurse revalidation tool within our Learning and Development programme has been received extremely well with very positive feedback from staff. Both the revalidation tool and the draft version of the NCC electronic tool has been demonstrated to the CQC

7.2 National Recommendations



Highly rated nurse;

Uro-oncology nurse specialist, Richard Turner, has been approached by the Product Manager of IWantGreatCare because he is the most highly rated and reviewed nurse in the country. Richard has been asked if he would be willing to be involved in an iWGC case study in order to help other nurses achieve similar reviews.

UHMBT teams shortlisted for awards include:

Flourish physical activity – shortlisted for ‘Sports and Physical Activity’ award with MSH Partnership (UK); final on 22nd November by Prof. Sir Bruce Keogh (lead director, David Walker)

Maternity Matters, shortlisted for North West CIPR Pride Awards; final on 3 November 2016 (lead director, Sue Smith)

Comprehensive Nursing Digital Record, shortlisted in the Technology and Data in Nursing category of the Nursing Times Awards, final on 26th October (lead director, Sue Smith)

Hospital Alcohol Liaison Service (Hospital Alcohol Liaison Service) University Hospitals of Morecambe Bay NHS Trust and Red Rose Recovery, shortlisted in the Emergency and Critical Care category of the Nursing Times Awards, final on 26th October (lead director, Sue Smith)

8. Recommendation

The Board of Directors is asked to note the content of this paper.



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Web viewParticipants observe live surgery and discuss ... This smaller group option may be a mix of presentations, case reviews ... the orthopaedic theatre team and