Download Six monthly report - Wye Valley NHS Trust

TRUST BOARD MEETING
Report to:
Date of Meeting:
Title of Report:
Trust Board Meeting “in public”
Agenda item:
14
4th June 2014
Nurse and Midwifery capacity and capability 6 monthly
review
Status of report:
For approval
(decision and approval, position statement,
information, confidential discussion)
Lead Executive Director:
Michelle Clarke, Director of Nursing and Quality
Author:
Paul Hooton Deputy Director of Nursing
Appendices:
Appendix 1 –recruitment in areas
Appendix 2 – Nurse Sensitive Indicators comparison
1.
Purpose of the report
This paper will update the Board on the current nurse, midwifery and District Nursing staffing levels building upon
the previous nurse staffing capacity and capability report that came to Board in November 2014.
This report has been prepared following a full review of nursing, midwifery and District Nursing staffing levels
across all clinical areas which takes place on a six monthly basis.
The review has been undertaken by the Director of Nursing and Quality, the Deputy Director of Nursing, the Ward
Sister or equivalent, their Head of Nursing and the finance manager.
This report also sets out how we are meeting national staffing guidance to publish our nurse and midwifery
staffing levels for our inpatient bedded wards.
2. Recommendations
The Board are asked to: Review and be satisfied that the appropriate level of detail and assessment has been undertaken to assure
itself that the wards, departments and community service units are safely staffed.
 To note the challenges in recruitment – in particular medical wards and theatres.
 To note the key developments achieved in the last six months.
 To note the future workforce challenges.
3. Summary of Key Issues for discussion


Improvement in Nurse Staffing Indicators where establishment has improved/deteriorated where
establishment has not been fulfilled.
Recruitment challenges.
4. Reference to previous reports
Nurse staffing capacity and capability November 2014
5. For further information or any enquires relating to this report please contact:
Michelle Clarke, Director of Nursing & Quality. [email protected]
Paul Hooton, Deputy Director of Nursing.
[email protected]
6. Please confirm, by ticking the box, that you have included or considered the following items in
developing your report:
X
C
Background
X
Care Quality Commission Implications
X
Legal / NHS Constitution considerations
X
Analysis of Risk including link to the Board Assurance Framework and Risk Register
X
Resource Implications (staffing & financial)
X
Adult and Child Safeguarding
X
Patient, Public and Stakeholder involvement
1.0
INTRODUCTION
1.1 As part of the National Quality Board guidance published in November 2013 there is a requirement to publish
a six monthly review of the nursing establishment .This allows patients and the public to see how hospitals are
performing on this indicator in an easy and accessible way. The data sits alongside a range of other safety
indicators. These include CQC ratings, infection and cleanliness, open and honest reporting (patient safety
incidents on NRLS), VTE risk assessment, response to patient safety alerts, NHS staff survey (staff
recommendation) and the NHS Safety Thermometer.
2.0
Main Body of Report
2.1 Nursing and midwifery establishments are reviewed bi-annually to ensure the nursing and midwifery
workforce meets the demands of clinical care provision and delivers safe care with a positive patient experience.
We triangulate our information gained by two methods to set ward establishments.

Safer Nursing Care Tool which has been validated by NICE

Professional judgement
The data from the acuity tool provides recommendations for establishment and this is supported by the
professional judgement of the nurse leader to form the staffing requirements of the areas and a formal discussion
with the Director of Nursing and Quality.
The Safer staffing six month review took place over 21 days from the 2nd to the 22nd of February 2015. There was
a 100% compliance rate. In April the Director of Nursing and the Deputy Director of Nurse met with clinical areas,
finance and heads of nursing to review the data capture along with Nurse Sensitive Indicators and Whole Time
Equivalents (WTE) in order to clarify current staffing establishment and identify any gaps.
The data from the acuity tool provides recommendations for establishment and this is supported by the
professional judgement of the nurse leader to form the staffing requirements of the areas and a formal discussion
with the Director and Deputy Director of Nursing and Quality.
The results demonstrated little change in acuity for clinical areas and staffing levels were correct.
Appendix 1 gives an overview of each clinical area` s report.
2.2 Recruitment and Retention.
The report highlights the difficulties with recruitment and retention as many areas have high vacancy rates. A
number of initiatives are in place to address this. The Trust has successfully recruited 72 ward based Filipino
nurses and 14 theatre based Indian nurses who will be joining the Trust from September. We also had a very
successful local recruitment event with at least 20 nurses expected to join the Trust over the next few of months.
A proportion of these will be return to practice nurses.
In the short term additional band 2 Healthcare Assistants (HCAs) have been employed to support the nursing
workload on a risk assessment basis in some clinical areas and we are exploring the employment of band 4 HCAs.
Some wards have blocked book bank and agency staff to help fill the gaps and support continuity of care.
In order to ensure our staffing establishments are met on a shift by shift basis a number of processes are in place

Electronic staff rostering

Nurse staffing escalation policy

Patient flow report throughout a 24 hour period identifying red and amber areas for staffing concerns

Monthly reporting to Trust board
A recruitment and retention working group has been established to develop the medium and long term strategy.
2.3 Band 4 HCAs
It has long been recognised that band 4 roles could undertake many of the nursing tasks performed by the
registered nurse leaving the nurse to undertake more complex care, assessment and clinical skills. With the
increasing difficulties in recruiting to band 5 posts this has become a very real alternative. The Deputy Director of
Nursing has put together a short working group to explore this in more detail and develop an implementation
plan. Potential clinical areas to utilise Band 4s will be the community hospitals, stroke ward, some of the acute
medical wards, emergency department and some surgical wards.
2.4 E-Rostering review.
The Trust is currently reviewing the staff electronic rostering system (E-Rostering). This is to ensure that we are
making the most of the staff that are available, ensuring we have effective and harmonised shift patterns,
transparency and visibility of staff rosters to enable the deployment of staff appropriately.
2.5 Nurse Sensitive Indicators (appendix 2)
The majority of clinical areas have seen no change or slight increase in their Nurse Sensitive Indicators particularly
in regards to drug errors and slips trips and falls. All areas have had their uplift in staffing numbers for over a year
now , however they may have got to full complement and then other members of staff have left. This has
resulted in high use of bank and agency nurses in some areas. This inevitably increases the risks of errors. It is
also noted that there was an increased number of clusters of Clostridium Difficle outbreaks over the month of
February. The infection control team has undertaking a detailed route cause analysis and as a result is
implementing a number of actions for Clostridium Difficle including updating the cleaning protocol , deep clean
process and signage used during closure of wards.
Appendix 1
Elective
Teme The six month acuity review has shown the current establishment is correct. The vacancy rate is currently
2.8 WTE. Recruitment of band 5 posts is challenging and the ward is exploring the possibility of a band 4 post to
substitute for one of the band 5 vacancies. Sick levels remain
Leadon The six month acuity review shows the current establishment is correct. The ward currently has 7 WTE
band 5 vacancies. However they have recruited one European nurse in the last month. The band 4 role is well
established on the ward and they are planning on increasing this workforce to mitigate the band 5 vacancies. The
recent increase in vacancies and the increase in medical outliers have had an impact on the clinical area with an
increase in drug errors and Clostridium Difficle over the past six months.
Monnow The six month acuity review has shown the current establishment is correct. Their vacancy rate is low at
2.8 Band 5’s and they have no long term sick or maternity leave. The Nurse Sensitive Indicators are scoring green
for the majority of indicators over the past six months; however there has been a slight increase in drug errors.
They are current exploring a pilot using prepared intravenous antibiotics with pharmacy which will release nursing
time and reduce the risk of errors.
Redbrook The six month acuity review has shown the current establishment is correct the ward sister reported
that the ward experienced a high number of acuity patients due to medical outliers. Their vacancy rate improved
from September with only 1.8 WTE posts vacant. They are also considering how they might use a band 4 role
within the ward. The Nurse Sensitive Indicators show an increase in the last 6 months in slips, trips and falls and
Clostridium Difficle cases. This would tally with the increased acuity level. There has however been a decrease in
drug errors.
Urgent Care
AAU The vacancy rate remains high with 14 WTE band 5 posts. In addition to this they have a small amount of
sickness and maternity leave. The ratio for this ward of nurse to patient is higher here as it is an acute admissions
unit (1:4). This shortage is reflected in the Nurse Sensitive Indicators as AAU in particular drug errors and slips
trips and falls has increased over the past six months. The ward has experienced a particularly high volume of
dependent frail elderly patients over the past 3 months which has added to the clinical pressures, this was as a
result of the new frailty assessment unit. In the meantime, they are addressing their staffing shortages and have
successfully appointed 3 newly qualified nurses, 1 EU nurse and 5 Filipino nurses. All should be in post by
September 2015. Current vacancies are being covered by block booking of bank and agency nurses for continuity.
Arrow. The six month acuity review has shown the current establishment is correct. Arrow still has a vacancy rate
of 5.4 WTE. There is a small amount of sickness and maternity leave. However 4 Filipino nurses have been
recruited and will start in September. The Nurse Sensitive Indicators have seen an increase in drug errors, patient
falls in the last six months. This in part is due to the vacancy rate on the ward. There has been however no
reported Clostridium Difficle cases over the same period. The ward already has an established band 4 role and is
exploring the possibility of increasing this.
Wye From the 1ST of April this ward is the dedicated stroke ward and as such has had an up lift of staff to meet
the increased acuity of the patients to meet a nurse /patient ratio of between 1to 6 patients and 1 to 8 depending
on the acuity of the ward . Therefore there was an overall increase from 38.63 to 52.25 WTE .They have not been
able to recruit to all vacancies as yet. However they have successfully recruited 5 Filipino nurses commencing in
September along with 2 Newly Qualified Nurses. The band 4 role is well established on the ward. The workload of
the ward is well suited to employing additional band 4 staff. To this end the ward is currently recruiting an
additional 6 band 4 HCAs over the next 6 months in order to reduce their band 5 vacancy rate. Bank and agency
nurses have been block booked to support the ward. Nurse Sensitive Indicators show an increase in Clostridium
Difficle cases and slips trips and falls but show a decrease in drug errors and clinical complaints. The ward team
are putting together an action plan to reduce its falls rate.
Lugg
The six month acuity review has shown the current establishment is correct. Lugg ward has had a
significantly high band 5 vacancy rate (11.4WTE) which has resulted in issues and concerns with staff morale and
patient safety. To resolve this in the short term they have blocked booked agency nurses and band 5 from other
clinical areas have been seconded in to support the ward along with over recruiting to the band 2 workforce.
Moving forward they have successfully recruited 5 Filipino nurses, 1 EU nurse and a newly qualified Nurse all to
start in September .They are also scoping the role of a band 4 worker. Nurse Sensitive Indicators have seen an
increase in drug errors slips trips and falls along with clinical complaints. These are most probably related to the
staff shortages and increase in agency use.
Community Hospitals
The majority of the hospitals have seen a reduction in most of their Nurse Sensitive Indicators with the exception
being both an increase in Clostridium Difficle in Ross and Bromyard hospitals. Hillside has also seen an increase in
slips trips and falls over the past six months.
Hillside as part of the safer staffing review the director of Nursing and Quality has agreed to a new staffing skill
mix from the original proposal when stroke rehab moved to Wye Ward. This is within budget and sees an increase
in HCA’s but still maintains a ratio of 1:8 for qualified nurses.
Ross currently has 2 Band 5 vacancies. The restructuring of the skill mix on nights is working well. Ross has also
reported an improvement on their length of stay.
Leominster Community Hospital currently has 1.22 Band 5 vacancies. They are currently supporting 2 Return to
Practice nurses with the intention of employing them once they have completed their programme in July. They
have also improved on their Length of Stay form 15 days to 13 days. They are aiming to achieve 10 days by the
end of the year.
Bromyard Community Hospital has a third of posts vacant (3.47 WTE) in Band 5’s. They have appointed a newly
qualified nurse who will commence in September. Band 4 HCA role is also being explored here, the ward report
they are experiencing more complex patients and despite their length of stay been down, they have difficulties at
times with cross border discharges.
Other areas
Critical Care Has a 0.46WTE band 6 vacancy. Nurse Sensitive Indicators are green except for 4 drug errors and 1
pressure ulcer. They are intending to extend their outreach service to 12 hours a day 7 days a week.
Theatres have completed their workforce review and are now staffing their Theatres in accordance with the
Association of Peri-operative practice which is 3 band 5s and 1 band 2 pre theatre. They currently have 14.5 Band
5’s vacant posts. However they have recruited 14 overseas nurses who will be in post in September. In the
meantime they have 7 permanent agency staff in place.
Midwifery Birth to midwife ratio is now 1:28 following successful recruitment to all vacancies. Moving forward
Safe Midwifery Staffing in Maternity Setting have been recently published by the Department of Health and will
be included in the next 6 month review in November.
Women’s Health is at full establishment. Their Nurse Sensitive Indicators is predominately green however there
has been an increase in drug errors over the past six months. The new skill mix should reduce the risk of drug
errors.
SCBU is at full establishment.
Children’s Ward Continues to see an increase in admissions over the winter months which is not accounted for in
the establishment. They use additional bank and agency to cover the increased work load. Currently have 2 WTE
band 5 vacancies. System resilience monies have been used for winter increase in activity and a business case will
be put forward for the following year.
Emergency Department currently has 10.53 WTE Band 5 vacancies. There is an ongoing recruitment campaign.
They are also looking at different ways of working including band 4 roles and physiotherapists. Safer Staffing for
Emergency Department will be published in the summer. The draft guideline suggests that we are compliant for
major and minor injuries but will need to review the Resus staffing numbers.
Clinical Assessment Unit currently has 2.6 WTE Band 5 vacancies.
Coronary Care Unit currently is at full establishment.
District Nursing
NICE have produced Safer Staffing guidance for District Nursing. It is currently out for
consultation. Once ratified District Nursing safer staffing numbers will be included in this paper.