3 - Nursing Establishment Review · Establishment review for inpatient areas, excluding Maternity....

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NLG(19)216

DATE OF MEETING

3rd September 2019

REPORT FOR

Trust Board of Directors –Public

REPORT FROM

Ellie Monkhouse, Chief Nurse

CONTACT OFFICER

Ellie Monkhouse, Chief Nurse

Elaine Coghill, Deputy Chief Nurse

SUBJECT

Annual Safe Staffing & Establishment Review for inpati ent areas

BACKGROUND DOCUMENT (IF ANY) National Quality Board (NQB)( 2016)

Developing Workforce Safeguards NHSI (2018)

PURPOSE OF THE REPORT:

The Board is provided with the Annual Report for Safe Staffing & Establishment review for inpatient areas, excluding Maternity.

EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)

As part of the National Quality Board (NQB) 2016 requirements around the monitoring of sustainable safe staffing levels on inpatient wards, provider Trust Boards are required to receive an annual review and approve any changes to nursing establishments. From April 2019 NHS providers are also assessed against new guidance: Workforce Safeguards Guidance (NHSI 2018) to support the application of workforce planning and safe staffing decisions.

The nurse staffing review was carried out using methodology described by the NQB (2016) guidance for thirty one wards across all sites for adult and children inpatients. A rolling process is in place to ensure that six monthly reviews take place to reflect potential seasonal changes. The next adult and children’s inpatient review is due to take place in September and October 2019. ED was reviewed by NHSI and is included in this review but not using the SNCT. The publication of the ED SNCT is expected towards the end of 2019.

• The critical care and high observation areas review

against national critical care guidance are scheduled to commence in August 2019.

• Community Service will commence a review later in the year following their service review.

• A review day surgery, theatres and planned investigation units towards the end of the year following theatre productivity reviews.

• A Maternity review will take place during September/October 2019.

As this process is new to the Trust and there were and continue to be , significant training needs and the process will take a while to embed. It is currently having to be deployed in stages so appropriate support and guidance can be provided. As this is a

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robust data driven, analytical process it does require and significant amount of time and oversight from the Chief Nurse and Deputy Chief Nurse to be able to provide the level of detail required to adhere to the standards.

The reviews undertaken in adult and children inpatient areas considered a triangulation of elements for each ward and included a celebration of what is going well. A consistent theme from the ward managers included vacancies, managing short term sickness and ability to cover rosters within the ward establishments as well as issues with training requirements and uplift. Despite this improvement was noted in statutory and mandatory training and appraisal rates, with most wards advising that they were near completion. A concern highlighted was the recurring theme across the teams regarding high patient activity and transfer out of hours.

• Reduced nursing cover on a night shift with continued

high patient activity. • Variation in shift patterns. • Some discrepancies with ward budgets not being

calculated to cover a 24 hour period so wards at full establishment were not always able to cover a roster.

• More consistency in reviewing and signing off rosters well in advance.

• Budget meetings inconsistent in some ward areas. • Ward clerks not being part of the nursing team and not

working later into evening hours and at weekends. • Inconsistency of care navigators and clinical ward sisters

on wards. • SNCT data demonstrating that on some wards staffing

RN establishment level is low. • CHPPD is low on more general wards. • Skills mix is in the majority outside national limits.

Some of the Recommendations:

1. Introduce a twilight RN shift in many areas with high

patient activity during the evening. 2. Review areas where there was a difference in shift times

and budget allocation. 3. Review the patient care navigator role and clinical ward

sister. 4. Review ward clerk support, particularly out of hours and

at weekends. 5. Review nursing mandatory training requirements and

implement a new revised process to meet requirements. 6. To undertake a review with organisational development

into sickness levels and themes and activity. 7. To include the average patient movement per day in the

next SNCT review. 8. An annual review of how headroom is calculated to

reflect changes within the workforce. A board briefing and presentation was provided in August by the Chief Nurse to discuss in full the recommendations made within this paper. This has also been discussed on 2 occasions in August at the Trust Management Board. A recruitment process has begun for the first stage of meeting the recommendations within the report. A further update paper will be provided to the Trust Management Board on September 16th 2019 to provide details of the next phase of implementing the recommendations.

TRUST BOARD ACTION REQUIRED

The Board is asked to note and approve and recommendations within this report.

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Annual Safer Staffing and Establishment Review

1. Introduction

The purpose of this paper is to provide the Board with the annual nurse safe staffing review in line with the guidance and requirements as cited by the National Quality Board (NQB) Supporting NHS Providers to deliver the right staff, with the right skills, in the right place at the right time – safe, sustainable and productive staffing (NQB July 2016) and Developing Workforce Safeguards (NHSI 2018).

As part of the NQB 2016 requirements around the monitoring of sustainable safe staffing levels on inpatient wards, the Board are required to receive an annual review and approve any changes to nursing establishments.

The guidance:

• Sets out the key principles and tools that provider boards should use to measure and

improve their use of staffing resources to ensure safe, sustainable and productive services, including introducing the care hours per patient day (CHPPD) metric;

• Identifies three updated NQB expectations that form a ‘triangulated’ approach (‘Right Staff, Right Skills, Right Place and Time’) to staffing decisions.

2. Context

Developing Workforce Safeguards (2018), supports previous documents and requirements, building on the triangulated approach to safe staffing needs as described by the NQB guidance from 2016.The trust will be assessed with its compliance with this through the Single Oversight Framework (SoF) providing a statement within their Annual Governance Statement from April 2019.

Using this methodology will ensure that the Board can be assured that establishments are based on patient safety and acuity in line with CQC fundamental standards and use of resources , and therefore for fill the Boards statutory requirements:

NQB (2016) guidance states providers:

• Must deploy sufficient suitable qualified, competent, skilled and experienced staff to

meet treatment needs of patients safely and effectively. • Should have a systematic approach to determining the number of staff and range of

skills required and keep them safe at all times • MUST use an approach the reflects current legislation

Image 1 below, identifies the requirements of the Safe Staffing review and what must be considered as part of this review. This paper will identify how the review meets all of the expectations identified within the Developing Workforce Safeguards Guidance NHSI (2018).

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Image 1: The principles of Safe Staffing

The guidance also advises that boards must have a local dashboard that cross checks quality metrics and this should be reported monthly. The Chief Nurse has developed a nursing dashboard and nursing metrics panel which inform the nursing assurance report submitted to each board meeting to support these requirements.

A safe staffing review should be reported to the Board twice a year, based on evidence based tools, outcomes and clinical judgements. This paper will be the annual report to board, will a mid-year review. Over time this will allow us to develop more understanding of seasonal trends, or workforce patterns, but will also allow us to ensure there is a continuous review of safe staffing against patients acuity and dependency.

The reviews included:

• The Safer Nursing Care Tool (SNCT) • NICE Guidance (2014) Safe Staffing for Nursing in Adult Acute Wards in Acute Hospitals • Clinical / Professional Judgement • Model Hospital Data • Review of staffing red flags and staffing incidents • Triangulation of nursing metrics or nurse sensitive indicators through the nursing

dashboard and nursing metric panel. • Mandatory Training, appraisals and professional development • Recruitment and retention • Roster management • Budget management and staffing costs • Temporary staffing and fill rates

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Image 2: NQB methodology 2016 and 2018.

3. Methodology

The Safer Nursing Care Tool (SNCT) is defined as:

“An evidence based tool that enables nurses to assess patient acuity and dependency, incorporating a staffing multiplier to ensure that nursing establishments reflect patient needs in acuity/ dependency terms”.

The process involves using the acuity tool, over a period of 20 days on each area to establish patient need and dependency. This tool is based on 4 levels of care, defined by national guidance. See Appendix 1.

Data is then collected around levels of patient dependency and patient movements, including discharges, transfers, admissions, direct and indirect care, and occupancy. As this is the first time the trust has deployed this tool, activity data was not collected, but will be included in the next cycle. This data has been reviewed through the use of the staffing armoury calculator (SfH WPT 2010a).

The Chief Nurse sought training resource form NHSI to train all of our Ward Leaders, Matrons and other Senior Nurses across the trust about how to use the SNCT, this also included a clinical competency element based on the levels of care, which included an assessment of those who received the training by NHSI experts.

A project plan was then developed over an identified period of time on each site so that support, advice and validation could be provided by the Senior/corporate nursing team. All ward areas completed this process in a timely manner.

With support from the Improving Together Team the data was ran through the appropriate software, using specific SNCT calculations seen in Appendix 2. Once this data was completed, the ward review process then commenced.

3.1 Ward Review Process

As part of the new annual review thirty one wards across all hospital sites for adult and children inpatients were reviewed. A rolling process has been put in place by the Chief

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Nurse to ensure that a six monthly review takes place to reflect potential seasonal changes or demographic changes to wards. In gathering more robust, on-going consistent data, an average review of acuity is able to take place to provide on-going safe staffing reviews in line with trust reporting requirements and would enable any decision making around changes to be based on a strong evidence base. This information will also help us to understand the activity and flow through our organisation, which will support other executive decision making.

The ward review group consisted of the Ward Manager, Chief Nurse, Deputy Chief Nurse, (Transformation, Workforce Development & Professional Standards), Head of Nurse Staffing, Head of Nursing, Matron and Finance Business Partner. It is essential to include the clinical manager in the ward review process as they are the accountable leader and meetings were arranged to accommodate their attendance.

The ward review considered a triangulation of elements for each ward, which also included a financial review, an example of the template used is included in Appendix 3.

Information was taken from a 3 month review of the nursing dashboard, but also included: • Information from the SNCT review. • A review of ward budgets and establishments, with a clear breakdown of staffing budgets

at each band and non-pay, • Agency and bank use. • Roster management. • HR benchmarks including vacancy, sickness, appraisals, training and development. • National benchmarking of CHPPD data using the Model Hospital.

The review included a celebration of what is going well on the ward areas, which highlighted good practice and exceptional leadership. A consistent theme from the ward managers included vacancies, ability to cover rosters within the ward establishments, movement of staff out of hours and backfill of apprentices. There had been a significant increase in statutory and mandatory training and appraisal rates, with most wards advising that they are near completion.

As part of this process the Chief Nurse will be following up with the ward managers that took part in the reviews and asked them to complete a short questionnaire on how this process felt to them and how this might be improved going forward. The verbal feedback received has been very positive as they have shared that they were able to contribute to the decision making process.

At the end of each ward review a discussion and decision was made on what recommendations would be put forward, so the entire panel was in agreement.

4. Review of Results

4.1. SNCT results

The SNCT allows managers and practitioners to challenge historical staffing and address inequalities. The care levels and multipliers facilitate judgements and are an integral part of the Chief Nurse’s toolkit. The SNCT multipliers are based on dependency workload literature and empirical data. The trust used licensed software to gain this information. The SNCT takes into account headroom of 22%. The complete SNCT can be seen in appendix 4 and 5.

Graph 1 below shows a breakdown across the sites the acuity of patients.

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Nu

mb

er

of

Pa

tie

nts

Graph 1: Patient acuity levels

DPOW - Number of Patients at

each SNCT level

SNCT lvl 0 SNCT lvl 1a

SNCT lvl 1b SNCT lvl 2

36

2834 4012

687

SGH - Number of Patients at

each SNCT level



92

3247 2542

517

GDH - Number of patients at

each SNCT level



1

250

586

NLAG - Number of Patients at each

SNCT level by site

5000 4000 3000 2000 1000

0 SNCT SNCT SNCT SNCT

lvl 0 lvl 1a lvl 1b lvl 2

DPoW 4012 687 2834 36

GDH 250 1 586 0

SGH 2542 517 3247 92

Table 1 below, highlights the areas where there is significant difference of more than 3, Registered Nurses as a result of the SNCT Review. The numbers are based on Whole Time Equivalents (WTE).

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Table 1: SNCT with deficits of more than 3 RNs

Ward SNCT Result Current Staffing Difference B4* 22 16.42 5.58

C2 19 14.53 4.47

C5 19 14.94 4.06

C6 18.6 15.25 3.35

Stroke DPoW 21.1 14.40 6.7

16 22.2 13.95 8.25

17 21.4 13.73 7.67

22 23.9 18.89 5.01

23 24.5 18.89 5.61

24 26.4 18.89 7.51

CDU 22.7 18.89 3.81

B6 19.5 13.73 3.57

B7 19.5 14.45 5.05

25 19.2 16.2 3

*It is worth noting that B4 changed from a Surgical Ward in November 2018.

The wards identified with the highest difference in establishments were 16, 17, 24 and Stroke DPoW. These areas can be triangulated to the areas which have triggered various nursing metrics and highest areas of temporary staffing. These areas were also part of the New Deal for nursing review in June 2018.

4.2 Care Hours Per Patient Day (CHPPD) Data and Mod el Hospital.

CHPPD data has been collected for acute and acute specialist providers since April 2016 and for community and mental health trusts since April 2018, following publication of Lord Carter’s report on their productivity.

As a result of this:

• All trusts must submit CHPPD data via the Strategic Data Collection Service (SDCS).

• CHPPD is a measure of workforce deployment that can be used at ward level and

service level or aggregated to trust level.

• To calculate CHPPD, monthly returns for safe staffing and the daily patient count at midnight, which is the total number of patients on the ward at 23.59, are aggregated for the month.

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(Acute and specialist acute trust Care Hours Per Patient Day guidance update https://improvement.nhs.uk/documents/3177/CHPPD_guidance_-_acute.pdf)

The Chief Nurse has been using the Model Hospital to compare our CHPPD metrics against national peers since November 2018 on a ward by ward basis; this is reflected within the monthly nursing assurance report. A review of December 2018 data is included in Appendix 6. This has highlighted that some of the ward definitions are not correct and data being submitted is not accurate. Some wards are including ambulatory, frailty and high observations areas in their data returns. This is currently being reviewed and will be updated by the Deputy Chief Nurse and the Improving Together Team in conjunction with the Model Hospital Team. However, overall our trust benchmarks are poor for CHPPD and we have 19 wards below the national threshold.

Overall trust data of CHPPD should be viewed with caution, as it does not take into consideration elements within our model of delivery, and benchmarking against the nominated peers list, does not always provide a good comparator. It is also not clear the parameters of our peers as they include single site smaller trusts, with less acute services provided. It is therefore more useful to look at ward demographics.

Things for our trust to consider include:

• Changes to our reconfigurations of wards are impacting on the trust overall data.

• Lower occupancy on Children’s wards.

• The acuity of the service delivery model at the trust is currently is not taken into account,

i.e. escalation beds.

• Our ward demographics are not classified correctly.

• Goole site due to low occupancy/activity levels.

From Appendix 6, we can see that the majority of our wards benchmark below both peer and national CHPPD. We must also take into consideration occupancy levels at Goole when looking at the overall trust position of CHPPD. It would be useful to be able to review the trust data removing the Goole element to give a more realistic of the trust wide CHPPD data. Information by site on this is submitted as part of the nursing assurance report. CHPPD per ward are reviewed on a monthly basis as part of the Nursing Metrics Panel against national Model Hospital data.

During the period of the review, the latest Model hospital data from that period (Dec/Jan 2019) indicated:

Cost per WAU – RN

Trust Peer National £593 £592 £554

Cost per WAU – HCSW

Trust Peer National £196 £168 £155

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The Weighted Activity Unit (WAU) is a 'common currency' to describe an amount of clinical activity, with a weighting applied that takes account of case mix and complexity.

This identifies where we have been supplementing some trained nurses for HCSW’s and the use of supportive observations for some of our level 1b patients, which we can see from the SNCT results. This also reflects some of the use around temporary staffing to supplement the lower establishments in comparison to the SNCT calculation. Although the trust WAU for RN’s is slightly higher than the national average, we do compare with our peers favourably.

However it is interesting to note that our Cost of Care per hour is lower than national and peer organisations, see below.

Cost per hour – RN

Trust Peer National £28.93 £29.08 £29.90

Cost per hour – HCSW

Trust Peer National £17.11 £19.01 £19.17

It is worth considering what this might mean for the trust, it may reflect that this is the quarter after the September intake of students, so they will be at the lower end of the bandings, or that the activity on our wards is high. As discussed in the next section there were some wards with a concerning skill mix, so this may also be the reason of our lower costs, given the use of temporary staffing within the organisation.

Data from the Model Hospital is behind, with some data from 18/19, so whilst we do review this data, it doesn’t always provide up to date benchmarking information, but can be a useful benchmark to review establishments and compare.

Below in graph 2 we can see the split between CHPPD RN and HCSW against national and peer benchmarks.

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RN & HCA CHPPD - NLAG vs Peer vs National

4.7 4.6

4.5 4.5

Trust

Peer

3.5 3.3 3.3 National

2.5

Data

Source:

Model

Hosptial -

RN HCA

Graph 2: Split between CHPPD RN and HCSW

4.3 Skill Mix

As part of the ward review process a review of ward skill mix was appraised, as seen in Appendix 5.

The public inquiry into the Mid Staffordshire NHS Trust (Mid Staffs) released in February 2013 pointed to fundamental flaws in the structure and culture of the NHS, and how these had led to serious care failures. In relation to nurse staffing, the Inquiry highlighted, poor decision-making, a failure to undertake risk assessment when changing levels or skill-mix, privileging financial matters over quality and safety, failures of leadership, not taking senior nursing advice, and failure to act in the face of evidence (Francis, 2013).

The supply of registered nurse staffing has not matched increases in demand; staffing levels in Trusts are falling below the level identified as being needed. There is evidence that there has been a downward shift in skill mix; support staff numbers have increased at a faster rate than RNs. Whilst in the short term this may appear to offer a solution to the ‘balancing act’, research evidence to date suggests that substitution of RNs with less well trained staff is unlikely to represent an efficient or effective solution (Ball et al 2019).

Higher registered nurse staffing levels are associated with lower mortality, and the fact that fewer vital sign observations are missed is the most likely explanation for this. Increasing registered nursing staff by an hour for each patient per day could reduce the risk of death by 3%. If the ratio of healthcare assistants to nurses gets too high, the data also suggest that rates of missed vital sign observations and mortality increase in line with the extra registered nurse time spent supervising other staff (Aitkin et al 2016).

Variation in hospital nurse skill mix in NHS hospitals in England varies from a high of 79% professional nurses in some hospitals to a low of 47% in others (Ball et al., 2014).

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On days the RN/HSCW skill mix identifies out of 31 wards:

• 18 wards are below a 50% RN skill mix, with 7 of those areas between 43% and 49% RN rate.

• 13 areas are above 60% but these are in high dependency, assessment and paediatric

areas.

• Areas with the lowest RN ratios are Ward B4, Stroke Unit in DPoW. Ward 16, Ward 17, Ward 25, Ward 27 and Neurology Unit with all areas having an average of 43:67 ratio, which is below RCN guidance and best practice.

On nights:

• 13 areas are at a 50%, or below RN ratio, this is because most wards run on 2 trained

Nurses, except for assessment areas, high dependency and Paediatrics.

Increases in nursing skill mix, by having proportionately more registered nurses, may be cost-effective for improving patient safety. The relationship between staffing, safety or workload is complex which should only be dismissed with caution (Leary and Punshon (2019).

A new process has been put in place to support staff management and escalation since July 2019. A prospective rostering review called “Check, challenge and coach” has been put in place with:1. Ward managers and matrons; 2. Ward managers and Heads of Nursing; and 3. Heads of Nursing and the Deputy Chief Nurse, using the roster perform process to review staffing from the first level approval to two weeks before going live. This also allows a review of rosters and how these are being managed (Appendix 7). Daily staffing meetings are also undertaken and a “Safe Friday” Meeting has also commenced in July 2019 to manage any concerns for the weekend.

Graph 3 below outlines the trust skill mix which is significantly below the recommended national standard of at least 60%.

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Graph 3: RN skill mix by ward

The wards 60% or above include: • Amethyst (days only) • AMU (days only) – Assessment area, which should have higher skill mix • C1 Glover (CCU monitored beds) • 18 (specialist haematology (nights only 1 HCA small bed inpatient ward) • 19 (outpatient clinics days and no HCA nights, small number of beds) • CCU (monitored beds) • CDU (activity and admissions high through day and night) • Stroke (HASU unit increases skill mix, due to stroke responders • Disney and Rainforest (children’s wards skill based on RCN guidance) • 6 (elective surgery)

4.4 Out of Hours

Staffing incidents are reviewed at the monthly Nursing Metrics Panel meeting every month. The majority of staffing incidents are reported to occur out of hours (see appendix 8) following a review of staffing Incidents.

A review of falls data over the last 3 months shows that over 50% of patient falls occur at night when activity across the trust remains high and staffing is reduced.

Wards

35

Early

Late

Night

95 85

75

65

55

45

RN Skill Mix, by shift, by ward- Target 60% RN

% o

f R

Ns

- (T

arg

et

60

%)

Am

ethy

st

AM

U

B2

B3

B4

B6

B7

C1

Glo

ver

C2

C5

C6

Str

oke

Laur

el

Rai

nfor

est

War

d 16

War

d 17

War

d 18

War

d 19

War

d 22

War

d 23

War

d 24

War

d 25

War

d 27

War

d 28

CC

U

CD

U

Str

oke/

HA

SU

Dis

ney

War

d 3

War

d 6

Neu

ro

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Table 2: Review of Falls Data Dec 2018-Feb 2019

Month Total number 19:30-07:30 Harms total

(Low and above)

Harms 19:30 -07:30

(Low and Above)

Dec 2018 150 87 51 30

January 2019

155 87 42 19

February 2019

157 83 61 34

Staffing out of hours also remains an issue with the number of RN level dropping by on average 35% at nights (see graph 4) below that excludes ITU and NICU). Night shifts predominately commence at 7pm or 7:30pm for a twelve hour period. This is a fairly early start for night shifts, but at 7pm flow and activity is still high through the trust. This can be triangulated with patient flow activity and the use of agency across the wards, as we have seen reported in the Nursing Assurance reports to Board. To mitigate some of this risk there has been a block booking of agency assigned to wards and the Chief Nurse has added local Nursing red flags around to include ˃at least 50% of staff must be substantive.

The full list of red flags can be seen in appendix 9.

The transfer of patients and movement of staff was a clear feature of ward review discussions as the majority of this took place out of hours. The patient activity and patient flow also continues to be an issue out of hours however the trust currently has no system or mechanism to capture this data.

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NLAG - RN Levels Day vs Night (WTE)

1600.00

1400.00

1200.00

1000.00

800.00

600.00

400.00

200.00

0.00

Graph 4: RN levels day versus night (WTE)

May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19

RN WTE by Day 1225.531153.281174.681161.73 1124.85 1209.13 1201.59 1176.221193.121074.721164.14 1150.35

RN WTE by Night 804.79 771.18 790.99 785.66 763.11 806.90 786.96 797.89 806.37 723.98 805.00 781.31

Variance 420.74 382.10 383.70 376.07 361.73 402.23 414.64 378.33 386.75 350.74 359.14 369.04

4.5 Medical Outliers

A common theme from the ward reviews was the significant number of medical outliers in many specialties.

As a snap shot, the number of medical outliers across the trust by week in June 2019 ranged from 45-78.

The graphs below show where the medical outliers were cared for. The majority of outliers were seen on Amethyst, Ward B2, Ward B6, Ward 18, Ward 25, Ward 28, Ward 19 and Laurel.

Most surgical wards indicated a number of medical outliers, with a higher ongoing rate of medical patients. This will need further data collection and analysis around seasonal trends and effect on quality metrics. For surgical wards this could have significant impact on their nursing metrics as seen through reviews at the Nursing Metrics Panel.

WT

E

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Graph 5: Total number of outliers and A&E performance

4.6 Supportive Observation / 1 to1 care

Many clinical managers cited issues with an increased requirement in the need for patients to have one to one care. This can be seen in the trusts SNCT results, with the majority of our patients being within the 1b classification, this may also reflect the increase in medical outliers, but would also reflect the increase in costs.

Table 3, below shows a breakdown of one to one care for patients in both Medicine and Surgery.

Surgery costs are variable however shows a significant increase of nearly £12k spend in March 2018, B6 have the highest spend of 1 to 1 care. Medicine spend on 1 to 1 care is always over £8.4k per month with a maximum spend of £19.6k in November 2018 and £18.5k in March 2019. C6 are the highest spenders of 1 to 1 care with nearly £40k spend in total 2018/19.

100 80 60 40 20

% of patients seen within 4hr A&E target vs Number of Patient

outliers - June 2019

100.00% 80.00% % of patients 60.00%

seen within 4hr 40.00% 20.00% A&E target

0.00%

Date

DPOW -

Outliers

SGH -

Outliers No

. O

f P

ati

en

ts O

utl

iers

01

/06

/20

19

03

/06

/20

19

05

/06

/20

19

07

/06

/20

19

09

/06

/20

19

11

/06

/20

19

13

/06

/20

19

15

/06

/20

19

17

/06

/20

19

19

/06

/20

19

21

/06

/20

19

23

/06

/20

19

25

/06

/20

19

27

/06

/20

19

29

/06

/20

19

17

Table 3:

Medicine Division

Surgery Division Sum of Cost Year Month

1819 1819 1819 1819 1819 1819 1819 1819 1819 1819 1819 1819 Grand Total

Cost Centre Cost Centre Name AP01 AP02 AP03 AP04 AP05 AP06 AP07 AP08 AP09 AP10 AP11 AP12

202340 DPW SURGICAL WARD B2 210.90 833.97 272.40 682.21 244.64 864.67 3,108.78

202341 DPW SURGICAL WARD B3 374.39 828.70 1,488.51 2,026.78 733.36 5,451.73

202344 DPW SURGICAL WARD B6 932.25 1,242.10 901.44 933.22 969.25 589.28 185.27 3,822.80 1,062.01 10,637.62

202345 DPW SURGICAL WARD B7 171.10 2,734.08 776.82 597.56 729.51 1,467.28 6,476.35

202415 DPW CRITICAL CARE HDU 1,231.88 435.73 235.22 354.12 3,646.27 5,903.21

202541 SGH SURGICAL WARD 27 161.35 1,410.62 1,772.08 171.60 220.08 103.25 713.42 838.12 5,390.51

202542 SGH SURGICAL WARD 25 270.87 135.91 189.46 249.04 188.39 389.15 1,422.81

202543 SGH SURGICAL WARD 2 2,202.71 2,202.71

202544 SGH SURGICAL WARD 28 1,112.59 1,409.23 2,244.30 4,766.12

202740 GDH SURGICAL WARD 6 221.19 106.02 421.46 748.66

Grand Total 535.74 652.87 3,710.65 4,059.92 3,395.80 7,244.01 2,601.52 3,924.67 833.91 2,013.90 5,390.43 11,745.08 46,108.50

Whilst work is ongoing to develop and promote a supportive observation policy with tighter grip and control on spend. Some allowance within budgets needs to be considered as part of the review of headroom in the future. The use of cohorting within bays is already being promoted, but further work will continue on this over the next 12 months.

It is important to note that a review of 1 to 1 cover the monthly average for 2018/19 was £14k, compared to 2019/20 to date being £30k. A review of additional duties was undertaken in March 2019 with a consolidation of choices, therefore leading to more accurate recording and a reduction of cost.

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RN - Bank and Agency Fill Rates

90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00%

4.7 Temporary staffing

Below in graph 6 is the percentage of RN bank and agency fill rate that is requested and graph 7 presents the overall usage bank and agency against RN vacancies and sickness.

Graph 6: RN bank and agency fill rates

January February March April May June

% RN Filled by Bank 55.14% 59.60% 59.81% 59.25% 58.52% 58.37%

% RN Filled by Agency 44.86% 40.40% 40.19% 40.75% 41.48% 41.63% % RN Total Fill 82.19% 82.33% 83.19% 82.05% 83.35% 83.62%

Graph 7: RN bank and agency versus vacancy

%

19

The above graphs demonstrate that the bank and agency use and fill rates remain fairly static, even when there is an increase in vacancies. Over time of collecting this data, we should start to be able to see a seasonal trend to be able to plan our recruitment campaigns better. There has been a steady increase in sickness since December; the reasons for this are currently unclear and maybe related to roster planning.

4.8 Apprenticeships

Throughout the ward reviews it became evident that there was an issue with the number of staff on apprenticeship programmes. A review has discovered that across the trust there are 93 HCAs and 13 Care Navigators undertaking apprenticeships with some wards having as many as up to six staff on the programme. The significant cost associated with the backfill of the 20% off the job training and college days equates to £8,692 per week and £677,976 over the 18 month programmes that they are on. A breakdown can be seen in Appendix 10. The apprentices currently attend college 1 day per week. It is recognised that this is an important career opportunity for the trust and is essential for our career pathways; however it would appear that backfill cost has been an unintended consequence and it has been a contribution to cost around temporary staffing. This cost does not apply to Trainee Nursing Associates.

4.9 Headroom

The Auditor General (2002), Hurst (2003), Healthcare Commission (2005) and RCN (2006) all recommend flexible headroom allowances ranging from 22% to 25%. The SNCT tool has 22% time out allowance included in the multipliers and establishment. The Carter review (2016) recommended between 22% - 24%. Headroom is a judgement about allowing clinical staff time away from the clinical area to complete their professional and mandatory training requirements.

A review of the trust headroom assumptions can be seen below:

• The establishment uplift for annual leave and training is 20.29% (39 days for annual

leave and holidays and 5 days study leave). A review of mandatory training face to face requirement per year for nursing show that a total of 3 days is required which leaves only 2 days for any other training requirements and any specialist training.

• There is additional uplift of 5.93% included as a bank allowance to cover sickness and other leave, which includes maternity leave, however divisions have over established on carers and utilised this funding, leaving no additional costs to cover sickness or other leave. It is not clear whether this is funded and how this is used, as templates do not cover basic establishments.

• The electronic rosters are set up to allow a 22% allowance.

This implies that there is difference between e-roster template and finance template.

The RCN (2013) recommends an uplift of 25%, failure to calculate this and apply across all areas can lead to an increase in temporary staff, reduced compliance with mandated training, burn out and retention issues. Best practice identifies this should be reviewed annually based on the workforce profile of the organisation.

The NQB (2017) suggest:

• The average annual leave across the workforce based on Agenda for Change.

• Sickness based on organisational target level which is reviewed annually.

20

• Study leave, taking into account mandatory training. • Parenting/special leave – according to local policy.

• Other leave.

• Temporary staffing allowance is not useful and should be built into the baseline

establishments

A review of the nursing headroom is required in line with the guidance above, and this should be part of the annual review, this should include:

• Recruit substantively to Maternity posts.

• An agreed baseline Headroom should be agreed between the Chief Nurse, People &

Organisational Development and Director of Finance.

4.10 Time to Lead

The role and development of our Ward Managers is vital to the quality of care provided to our patients. They also provide support and development to new professionals coming to the organisation and support the senior nursing team in maintaining high professional standards. Within the current establishment 9.5 hours per week is provided to ensure support of the nursing team and manage the ward environment. A concern highlighted from this review was that Ward Managers were often not able to be able to get this time and is a source of ongoing concern for ward managers to be able to for fill the role. This was a recurring theme across all teams. The exception is on our Children’s wards where the ward leader has 37.5 hours but also supports and manages other services and nurse specialists and is in line with national guidance. Clear guidance would be provided about the expectations this would include, which would be supervising practice, working with new members of staff, supporting preceptees.

It is recommended that this is increased to 15 hours per week over summer months to support nursing development, roster management, PADR quality and compliance and leadership, with a reduction to 7.5 hours per week during December, January, February and August, months when activity across the trust increases.

Approximate cost at pay point 5 (mid-point), band 7, with 24% headroom for 15 hours is £369 per week, current cost is £234 per week for 9.5 hours. Based on 52 weeks, although this would be less due to annual leave:

Current arrangements, total annual cost approx. £12,168 New arrangements of 15 hours for 36 weeks and 7.5 hours for 16 weeks, total annual cost approx. £13,678

Total increase of approx. £1,510 across 30 wards = £45,300

(Please note this is an approximate cost, based on 52 weeks per year)

21

5. Highlights identified from the ward review proce ss with Ward Managers

5.1 Themes

• A change of shift patterns are required across the trust to backfill towards the end of the day, therefore a need for a twilight shift was highlighted, as heightened activity was still taking place on the wards after staffing had reduced for night shifts.

• Some discrepancies with Health Roster and lengths of shifts, meaning wards at full

establishment were not always able to cover a roster. Some ward budgets were not calculated to cover a 24 hour period.

• The trust’s uplift across all wards reviewed is 20.29% the allowance for sickness and

other leave is not included in this, therefore total uplift in the establishment is only 20.29%. The trust is below the national standard and SNCT guidance of 22%.

• Only 2% is allocated in the uplifts for training and following a review of all the face to face

mandatory requirements this means that the uplift is not sufficient to cover any additional training.

• Although Practice was improving about reviewing and signing off rosters well in advance,

this is a new process and not fully embedded.

• No additional funding has been included for the 1 to 1 carer requirements and apprenticeship backfill requirement.

• Most Ward Managers were not involved with budget meetings, and therefore were those

that were had been able to contribute and have oversight of their bank, agency and vacancy rate.

• The Patient Care Navigator and Clinical Sister role was not consistent across all ward

areas.

• Triangulation of areas with trigger points on Nursing Metrics.

• The role of the Ward Clerk working later into evening hours and out of hours would be useful on the wards that have the highest turnover of patients, as their activity continues into late evening, which is an additional pull on nursing resource. This is included within the tier 4 administration review and the findings from this review will be fed into this review.

• Deficient in current establishment against CNST

• Number of medical outliers and escalation beds not within divisional budgets.

• Movement of staff out of hours.

• There are risks in relation to RN recruitment that are a national issue. However this

should not detract from the RN establishment required according to the evidence based SNCT requirements.

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• Skill mix not meeting national guidance

5.2 Identified Good Practice/Celebration

(see appendix 11 for wards that have been assessed with the 15 steps Quality Improvements programme)

• All wards had shown improvement in their mandatory training compliance and PADR

rates

• Ward 22 had reduced the number of pressure ulcers by identify the risk using visual

“traffic light” magnets and responding to this by placing charts outside the bays to act as a visual reminder. This has indirectly reduced the number of falls on the ward.

• Wards with high vacancy rates still reporting low numbers of complaints, pressure ulcers

and falls.

• Good Nursing Leadership was seen in the majority of wards.

• Good reports about wards and training from universities and students, with a lot of wards

retaining students as substantive members of staff.

6.0 Emergency Department (ED) Review

The Emergency Care Intensive Support Team (ECIST) undertook a review of both ED staffing numbers and patient demand. Whilst ECIST do not make recommendations in relation to staffing establishments, their review is intended to provide a data driven approach to considering ED staffing and provide observations and suggestions that the trust may wish to consider.

At DPoW, there are noticeable mismatches around the 12 midday to 1500 period and the 2000 to 2300 period. When we discussed this with the team this matched their experiences on a shift basis. This may lead to a backlog in care activities, medication and treatment potentially affecting quality of care for admitted and non- admitted patients. There is an opportunity to improve this through a test of change moving some of the earlier shift starts to be 9, 10 or 11 to accommodate.

At the SGH site, where there is some ‘staggering’ of shift times, which demonstrates a closer alignment between capacity and demand. The nursing workload may still feel challenged around 2100 and may want to consider aligning this a little further to limit delay going into the night.

In both cases, this does not take account of bed availability (in particular, a number being allocated at the same time) natural surge, or skill mix nor does it include staff break times. These are subject to your local expertise and experience to consider how best to reduce or control these variables.

23

15

10

5

0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Current rota vs demand shape

15

10

5

0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Current rota vs demand shape

Graph 8: Shape of current staffing rota versus demand (DPoW)

Graph 9: Shape of current staffing rota versus demand (SGH)

The streaming nurse is well placed to be able to observe all patients in the waiting room. The model in both hospitals is a Band 6 nurse with appropriate skills. On the SGH site, however, this model is undertaken on a ‘pool’ basis by some Band 5 and some Band 6 staff who have elected to carry it out. Staff said this worked well for the department as some staff had experience to make decisions at Band 6 level but were less comfortable with leading the shift. Where systems have hybrid staffing roles such as this, there is a risk that areas can be prioritised or deprioritised depending upon the skill mix and needs on a shift, staff could opt to work for their preferences rather than the department need on some shifts. Streaming needs to be completed by an experienced ED nurse to make this process effective and safe.

The role of the senior nurse acting as both majors coordinator and ambulance handover is extremely challenging particularly at times of high activity/occupancy. This may lead to a difficulty in maintaining command and control within the department.

At DPOW staff are allocated into different roles within the department, with the clinical area split into different zones. This includes 2 staff to expedite ambulance handover, with 1 nurse to cover resus. There were also 13 majors cubicles including 4 high observation cubicles. During the day the rota has 10 RN’s and 5 HCA’s with a reduction (removing streaming and ambulance handover nurse) to 8 RN overnight and 3 HCA’s. There is some Emergency Nurse Practitioner (ENP) resource.

At SGH staff are allocated into different roles within the department with the department split into different zones. Staff are split by teams (red and blue) to manage the majors area more effectively. Shift patterns in the morning cover 1 nurse in each team, a nurse in charge, 1

24

ambulance handover nurse and 1 triage nurse. As the day continues, there are staggered shift times to more effectively match capacity to demand.

The Chief Nurse and divisional team were involved with the initial feedback and then worked to develop a review of staffing provision in line with the information provided. Following the review the ward managers from both sites and divisional team, including finance and the Deputy Chief Nurse met with the Chief Nurse.

The following was discussed and agreed to progress for support:

• To alter the day time shift patterns to include two RNs doing a 9am-9:30pm shift instead

of all ten staff doing a 7am to 7:30pm shift. Similar model to SGH.

• To review the night shift pattern for nurse staffing. Activity can be just as busy as the day shift and therefore the shift pattern should be altered to meet this increased demand. To consider a twilight shift seven days per week.

• To review senior nursing leadership, particularly overnight and consider the uplift of a

band 6 shift leader to a band 7 role. This would require a review of role and responsibilities, this was highlighted in the previous CQC inspection.

• There should be a flow co-ordinator from 10am to midnight. It was agreed that the shifts

should be split across the day.

• To review the educational need of the department and consider the recruitment of a band 7 clinical educator at both sites.

• To review the nurse bank to include paramedics.

7.0 Community Services

There are a number of productivity projects underway in the community nursing teams, however the community nursing teams must be able to operate on the basis of real time information in terms of staff deployment if we are to increase capacity by achieving maximum productivity and patient facing time. Previous calculations for the community nursing teams alone have shown that an average of 480 visits are carried out per day throughout the year which gives an indication of the scale of work that has to be planned and allocated every day.

Procurement of an intelligent scheduling system would optimise and coordinate visits for all community staff and, in doing so, would reduce the amount of time senior nursing staff spend allocating visits (currently estimated to be 4 hours twice per week per caseload holder – approximately 10 available per week), increases productivity (number of visits), efficiency (travel time and mileage) and ultimately patient facing time (quality).

Real time visibility of the location of staff will improve staff safety and appropriate allocation of unscheduled work. The Division would have visibility of capacity and demand on a daily basis that is real time allowing for confident re-allocation of visits and unplanned activity. Linking the scheduling system with E-roster will enable measurement of utilisation, productivity and efficiency. Visibility of this information would support a robust review of staffing levels within community nursing teams. A business case has been developed for procurement of an intelligent scheduling system with a cost of approx. £40k.This may ultimately help with an increase in productivity and a reduction of costs.

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8.0 Recommendations

1. Due to our service delivery model to look to move staff towards the later part of the day, to support the early evening to night time period. Most of the investment required is to support this. This will help realign skill mix.

2. To review the areas where there was a difference in shift times and budget allocation,

as this could be contributing to an increase in bank and agency.

3. Review how headroom is being set based on workforce profile and guidance and then as an annual review.

4. Substantive recruitment to Maternity leave.

5. Reinstate monthly ward budget meetings with ward managers; this has started to take

place following the ward reviews.

6. To consider the review of the Patient Care Navigators and how they are budgeted to the wards to be able to provide consistent support to the ward teams, across the week and assist more with patient flow and discharge implement Safecare to allow real time staffing management.

7. To consider a review of Ward Clerk support this is consistent across ward in and out of

hours.

8. Continue to work on length of stay of our patients and discharge planning, looking more to develop nurse led discharge and protocols.

9. To consider the inclusion of a supportive observation in the headroom, or top slice

budgets to cover this cost.

10. More data is needed in the future to enable the Chief Nurse to analyse data and gather assurance.

11. To consider the divisions being funded for the apprenticeship backfill.

12. Uplift the Ward Managers time to lead to 15 hours per week and 7.5 hours per week in

January, February and August.

13. Review staffing escalation policy and process.

14. Continue to develop the understanding and modules associated with e –roster, such as roster perform and safe care to allow real time staffing management,

15. Present an annual full review to Board and with a mid-year review.

16. Align the rosters, budgets and establishments, with a ‘sense check’ at each ward

review.

17. Consider the procurement of the community productivity tool.

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8.1 Ward Staffing recommendations

� To increase the number of wte RNs for a twilight shift on 17 wards (Amethyst, B4, C2, C5,C6, C7 stroke, 16,17,23, 24, CDU, B2, B3, B6, B7, 25 and 28: where patient activity remained high in the into the evening, poor CHPPD, skill mix and SNCT results)

� Care navigator to be additional to carer establishment on 10 wards and additional

HSCW on one ward (Amethyst, B4, C2, C5, C6, C7 stroke, 16, 17, B3, B6, B7 so all adult wards have a CN and where a CN replaced a HSCW previously)

� Increase RN establishment on two wards for long days weekend cover (C6 and C7 to

replace the lost RN WTE at the weekend which was implemented as part of the New Deal for Nursing, activity no different at weekend)

� Increase RN establishment by one on a busy surgical ward Monday to Friday early

shift (25 to cover busy ward rounds)

� Increase RN establishment on a long day by one on two wards (22 and B2 for poor skill mix and SNCT results)

� Increase RN establishment on nights on one ward (28 for poor skill mix, high activity

and SNCT results)

� Increase carer establishment on nights by one on two wards (16 and 17 where they have high dependency patients)

� Uplift a band 5 to band 6 on 2 ward areas (Neuro rehab Centre and CCU SGH to

have a 2nd band 6 nurse and be equitable with all other adult wards).

Overall costs for ward increases: £1,77, 860

8.2 ED staffing recommendation

� To introduce a band 5 twilight shift in ED seven days per week (high activity)

� To increase the number of flow co-ordinators to cover the hours 10am to 12 midnight (improve flow)

� To uplift the band 6 to band 7 shift lead in ED at nights (in line with NICE and CQC

guidance and high activity)

� To recruit two band 7 clinical educators in ED on both sites (in line with CQC guidance)

Overall costs for ED: £455,100

Total costs: £2,233,700 (costed in current headroom and aligning budgets to match roster/establishments)

An example of a ward breakdown of costs can be found in Appendix 12.

27

8.2 Other recommendations

� Increase the ward managers time to lead to 15 hours per week except for the months of December, January, February and August Total increase of approx. £1,510 across 30 wards = £45,300

� Procurement of Community Nursing productivity software = £40k

8.3 Total overall costs

£2 279,040

A supplementary discussion paper will be provided to board.

29

9.0 In Summary: As discussed in Section 4.1 the SNCT identified some differences with our current ward establishment, there has also been a consideration of a reduced skill mix in line with national best practice, with a notable reduction in workforce between 7pm and 7:30am. This triangulations with incidents and staff movement during this time, including staffing incidents.

• Most of the uplift to establishments is to support staffing into the early evening hours

• Increase time to lead from 9.5 to 15 hours per week, and reduce to 7.5 hours per week in

December, January, April and August during peak seasonal activity

• Care Navigator to be additional to HCSW establishment as this is currently inconsistent; this role could focus more on discharge support and length of stay outside of the nursing numbers.

• Review current headroom arrangements to ensure alignment of roster and finance

templates to ensure accurate data is presented to external agencies. 10.0 Risks and Benefits

There are several risks and benefits identified with this review:

Risks

• An increase in establishments may lead to an increase in vacancies

• It may lead to an increase in temporary staffing in the short term, however, having more

flexibility may help with the short term management of sickness and deployment of staff, this is currently an areas incurring high cost.

• A more robust recruitment and retention plan is needed to attract more people to the trust.

• Increase in staffing costs.

Benefits

• Support future staff surveys

• Better use of resources by having flexibility within the trust to redeploy staff for

supportive observations or manage short term sickness at short notice.

• Investment in Leadership and Staffing support, reputational development to attract staff.

• Enhance patient experience and quality of care. 11.0 Conclusion

• A full and comprehensive triangulated approach using recognised methodology and

clinical judgement has taken place in line with NQB (2016) guidance and NHSI (2018).

• A separate review of Community, Maternity, Theatres, Day care Surgery and Investigation Units is scheduled to take place in the coming months. This is to establish processes to support future annual reviews. Maternity review will take place every 6 months.

30

• The next inpatient review and SNCT is due to take place in September/October 2019.

• As data develops more analysis can be included around temporary staffing, recruitment and retention.

• The next SNCT review will include activity data around admissions, discharges and

transfers.

• The data requirements and resource within the team to be able to provide this information to be kept under review, to be able to provide this level information.

• An uplift in ward establishments based on SNCT, clinical judgement discussion with Ward

Leaders and indicators is needed during the evening.

• Ongoing investment in the Nursing Dashboard. The Board is asked to note and approve and recommendations within this report.

Paper prepared by:

Ellie Monkhouse Chief Nurse

Elaine Coghill Deputy Chief Nurse, lead for Transformation, Workfo rce Development & Professional Standards

Ryan Sutton Senior Improvement Project Manager

31st July 2019

31

References

Aiken,L. H. , Sloane,D. , Griffiths, P., Rafferty, AM, Bruyneel,L., McHugh,M., Maier,C. B., Moreno-Casbas,T., Ball, J.E. Ausserhofer,D., Sermeus, W. (2016) Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. British Medical Journal Quality & Safety;26:559–568.

Ball JE, Murrells T, Rafferty AM, et al. ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Qual Saf 2014;23:116–25.

Carter, (2016) Operational productivity and performance in English NHS acute hospitals: Unwarranted variations: An independent report for the Department of Health by Lord Carter of Coles. London: The Stationery Office. Department of Health, London.

Francis, R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Stationery Office, London’

NHS Improvement (2018) Developing Workforce Safeguards. Supporting providers to deliver high quality care through safe and effective staffing. NHS Improvement, London.

National Institute For Health And Care Excellence. Safe staffing for nursing in adult inpatient wards in acute hospitals. NICE, 2014: http://www.nice.org.uk/guidance/sg1 (accessed 31st July 2019).

National Quality Board (2016) Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time. Safe, sustainable and productive staffing. NQB, London. (updated 2017)

RCN (2013) Safe staffing for older people’s wards. RCN full report and recommendations. Publication code: 004 280; ISBN: 978-1-908782-15-1, p 8.

Skills for Health Workforce Projects Team (SfH WPT) (2010a) The Nursing Workforce Planning Tool. tinyurl.com/nursework

The Association of UK University Hospitals (AUKUH) 2014. Safer Nursing Care Tool Implementation Resource Pack. http://shelfordgroup.org/library/documents/Shelford_Safer_Nursing_23May14a.pd

32

Appendix 1 The Safer Nursing Care Tool (SNCT) descriptors are based on the critical care patient classification (Comprehensive Critical Care, DH 2000). The classifications are adapted to support measurement across a range of wards/specialities (SNCT descriptors Shelford Group, SNCT implementation resource pack 2014).

Levels of Care Descriptor

Level 0

Patient requires hospitalisation

Needs met by provision of normal ward cares.

Multipliers

Adult 0.99

Acute Assessment 1.27

Care requirements may include the following

• Elective medical or surgical admission • May have underlying medical condition requiring on-going treatment

• Patients awaiting discharge

• Post-operative / post-procedure care - observations recorded half hourly initially then 4-hourly

• Regular observations 2 - 4 hourly

• Early Warning Score is within normal threshold.

• ECG monitoring

• Fluid management

• Oxygen therapy less than 35%

• Patient controlled analgesia

• Nerve block

• Single chest drain

• Confused patients not at risk

• Patients requiring assistance with some activities of daily living, require the assistance of one person to mobilise, or

33

experiences occasional incontinence

Level 1a

Acutely ill patients requiring intervention or those who are UNSTABLE with a GREATER POTENTIAL to deteriorate.

Multipliers

Adult 1.39



• Increased level of observations and therapeutic interventions • Early Warning Score - trigger point reached and requiring escalation.

• Post-operative care following complex surgery

• Emergency admissions requiring immediate therapeutic intervention.

• Instability requiring continual observation / invasive monitoring

• Oxygen therapy greater than 35% + / - chest physiotherapy 2 - 6 hourly

• Arterial blood gas analysis – intermittent

• Post 24 hours following insertion of tracheostomy, central lines, epidural or multiple chest or extra ventricular drains

• Severe infection or sepsis

Level 1b

Patients who are in a STABLE condition but are dependent on nursing care to meet most or all of the activities of daily living.

Multipliers


• Complex wound management requiring more than one nurse or takes more than one hour to complete. • VAC therapy where ward-based nurses undertake the treatment

• Patients with Spinal Instability / Spinal Cord Injury

• Mobility or repositioning difficulties requiring the assistance of two people

• Complex Intravenous Drug Regimes - (including those requiring prolonged preparatory / administration / post-administration

34

Adult 1.73


care) • Patient and / or carers requiring enhanced psychological support owing to poor disease prognosis or clinical outcome

• Patients on End of Life Care Pathway

• Confused patients who are at risk or requiring constant supervision

• Requires assistance with most or all activities of daily living

• Potential for self-harm and requires constant observation

• Facilitating a complex discharge where this is the responsibility of the ward based nurse

Levels of Care Descriptor

Level 2

May be managed within clearly identified, designated beds, resources with the required expertise and staffing level OR may require transfer to a dedicated Level 2 facility / unit

Multipliers

Adult 1.98



• Deteriorating / compromised single organ system • Post-operative optimisation (pre-op invasive monitoring) / extended post-op care.

• Patients requiring non-invasive ventilation / respiratory support; CPAP / BiPAP in acute respiratory failure

• First 24 hours following tracheostomy insertion

• Requires a range of therapeutic interventions including:

• Greater than 50% oxygen continuously

• Continuous cardiac monitoring and invasive pressure monitoring

• Drug Infusions requiring more intensive monitoring e.g. vasoactive drugs (amiodarone, inotropes, gtn) or potassium, magnesium

35

• Pain management - intrathecal analgesia

• CNS depression of airway and protective reflexes

• Invasive neurological monitoring

Level 3 Care requirements may include the following

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

Multipliers

Adult 5.99


36

Appendix 2 SNCT – Calculation assumptions

Uplifts (sickness / AL / SL)

Definition “Enter your local time-out uplift (sickness, annual and study leave, etc.) the default, 22.6%, which is an average of 1700 wards.” NLAG - This has been left at the default level of 22.6%

Ready for action time (RforA time)

Definition - The 9.7% (for Adult inpatient & AAU) and 11% (Children and Young people) means that we are deducting almost 10% ready-for-action time (the average from 1700 wards in the nursing database). Think carefully about raising or lowering the RfA time before you change it.

NLAG – This has been left at the default of 9.7% (Adult / AAU) / 11% (CYP)

RN proportion

Definition – “ RN to SW ratio the default is a 66:34 RN to SW ratio; i.e., two thirds will be RNs.

NLAG – 60% RN to 40% HCA has been applied.

Bench Marking

Definition “The percentages are the average SNCT level in 14 specialties so that you can benchmark your percentages for your ward. “

NLAG - wards are mixed speciality ward and therefore it will not be easy to apply these bench marks but are a useful reference point.

SNCT score Cardiolog CCU Children's ENT Med Eld Medicine Neurolog yOnc/Hae Orthopdc Rehabltn Renal Sroke Surgery Trauma Level 0 53% 52% 38% 73% 32% 40% 31% 38% 42% 38% 33% 21% 62% 34% Level 1a 18% 19% 25% 12% 2% 10% 26% 26% 22% 7% 6% 7% 15% 5% Level 1b 17% 15% 24% 7% 66% 48% 42% 35% 34% 52% 59% 67% 22% 57% Level 2 6% 12% 9% 3% 0% 1% 1% 2% 1% 4% 3% 6% 1% 2% Level 3 6% 2% 4% 6% 0% 2% 0% 0% 0% 0% 0% 0% 0% 3% Number of patients

in benchmark

1937 433 11500 173 1973 12162 2837 3761 2311 937 1741 2335 13334 2109

Note - Definitions provided by the SNCT 2019 calculators.

37

Appendix 3

NLaG Ward / Department Quality Metrics, Establishme nt and SNCT Review Date

Present: Corporate:

Quality

Ward Dashboard - previous 3 months data

Dec 2018 January 2019 February 2019

Occupancy

Activity transfers (discussion)

Fill Rates RN Days

Fill Rates Carer Days

Fill rates RN Nights

Fill rates Carer Nights

CHPPD RN

CHPPD Carers

CHPPD total

Staffing Incidents

Incident description

Vacancies total

Vacancies RNs

Vacancies Carers

Falls No harm

Falls Harm

Trends (discussion)

SI’s total

SIs (discussion)

38

Hospital Acquired Cat 2



Tissue Viability (discussion)

Safety Thermometer harm free

Complaints total

Complaints (discussion)

C diff lapses in care

Hand hygiene

Outbreaks

Dementia (discussion)

Patient Experience (discussion)

FFT response rate

FFT feedback discussion

What’s going well

What’s not going well

PADR

Mandatory training

39

Training & Education (discussion)

Staff health & Wellbeing (discussion)

Student Feedback (audits) discussion

Trainee nursing associate

ACP

Care Navigator

AP (4)

Staffing Headcount wte

Uplift total Annual leave & training

Sickness

Other Bank

25.93% 20.29%

4.1%

1.5%

(5.93)

Current bed numbers

Current Planned levels E

L

N

Skill Mix

Band 7 wte

Band 6 wte Band 5 wte

Band 5’s under 12 months qualified (discussion)

Band 3 wte

Band 2 wte

40

Ward Clerk (discussion)

Number of Staff

Absent due to Sickness

Absence B6 DPoW

H

ealth

care

Ass

ista

nt

S

taff

Nur

se

Sis

ter

G

rand

Tot

a

Lo

ng T

erm

A

bsen

ce

S

hort

Ter

m

Abs

ence

Dec-18

Jan-19

Feb-19

Narrative re HR support.

SNCT The below table shows the number of average patients at each SNCT level based on 20 days’ worth of data collected by the ward.

SNCT Element SNCT Your Ward

Level 0 patients (daily average)?

Level 1a patients (daily average)?

Level 1b patients (daily average)?



Patients

The below include 22% allowance for AL/SL etc, 9.7% for non-clinical activates during a shirt. Also based on a 60/40 RN/HCA split

Healthroster Rotas (discussion)

Staffing SNCT Current

RNs required 22.7

HCAs required 9.7

Total FTEs required 32.4

Future Workforce plans (discussion)

Flexible working (discussion)

Business cases

41

(discussion)

Finance To be completed by Finance

Budget u/o

Discrepancies

Qualified

Non-Qualified

Band 2

Band 3 Uplift

To be completed by Finance

Future staffing proposals (discussion)

Agreed recommendations (discussion)

42

Appendix 4: SNCT summary

Med

icin

e D

PO

W

Amethyst AMU B4 C1 Glover (CCU/C1K)

C2 C5 C6 Stroke

SN

CT

Est

ablis

hed

SN

CT

Est

ablis

hed

SN

CT

Est

ablis

hed

SN

CT

Est

ablis

hed

SN

CT

Est

ablis

hed

SN

CT

Est

ablis

hed

SN

CT

Est

ablis

hed

SN

CT

Est

ab

lish

ed

RN

s re

quire

d 17.8 17.02 20.7 24.68 22.0 16.42 8.8/ 19.3

13.73/ 14.40

19.0 14.53 19.0 14.94 18.6 15.25 21.1 14.40

HC

As

requ

ired 11.9 13.57 13.8 18.85 14.7 13.47 5.9/ 12.8

5.16/ 15.12

12.6 18.75 12.7 15.88 12.4 15.95 14.1 19.84

Tot

al

FT

Es

requ

ired 29.7 30.59 34.5 45.53 36.7 29.89 14.7/

32.1 18.89/ 29.52

31.6 33.24 31.6 30.81 31.0 31.20 35.2 34.24

* AMU indicates over establishment. However the AMU establishment was previously based on additional 12 beds which have now been removed to replace frailty and ambulatory bays.

43

Med

icin

e S

GH

& G

oole

16 17 18 22 23 24 CCU** Stroke ** 3 CDU S

NC

T

Est

ablis

hed

SN

CT

Est

ablis

hed

SN

CT

Est

ablis

hed

SN

CT

Est

ablis

hed

SN

CT

Est

ablis

hed

SN

CT

Est

ablis

hed

SN

CT

Est

ab

lish

ed

SN

CT

Est

ab

lish

ed

SN

CT

Est

ab

lish

ed

SN

CT

Est

ab

lish

ed

RN

s re

quire

d 22.2 13.95 21.4 13.73 8.9 10.8 23.9 18.89 24.5 18.89 26.4 18.89 9.3 15.15 14.2 28.76 12.9 13.35 22.7 18.89

HC

As

requ

ired 14.8 16.07 14.3 16.52 6.0 8.82 15.9 20.32 16.3 17.82 17.6 16.25 6.2 5.28 9.5 15.38 8.6 9.9 15.1 16.25

Tot

al

FT

Es

requ

ired

36.9 30.02 35.7 29.97 14.9 19.63 39.8 39.21 40.8 36.71 44.0 35.14 15.5 20.43 23.7 44.15 21.5 23.34 37.8 35.14

44

Surgery DPOW B2 SAU B3 B6 B7

SNCT Established SNCT Established SNCT Established SNCT Established

RNs required 23.7 21.07 20.4 24.05 17.3 13.73 19.5 14.45

HCAs required 15.8 17.02 13.6 13.70 11.5 13.47 13.0 14.18

Total FTEs required

39.4 38.08 34.0 37.75 28.8 27.20 32.4 28.63

Surgery SGH 25 27 28 (ward only) 6

SNCT Established SNCT Established SNCT Established SNCT Established

RNs required 19.2 16.2 17.7 19.9 17.86 17.86 7.3 13.02

HCAs required 12.8 16.01 11.8 13.3 15.75 15.75 4.9 4.47

Total FTEs required

32.0 22.22 29.5 33.2 33.61 33.61 12.2 17.67

Children’s DPOW & SGH

Laurel ** 19 ** Rainforest *** Disney*** NRC

SNCT Established SNCT Established SNCT Established SNCT Established SNCT Established

RNs required 22.8 17.09 8.2 14.15 18.1 22.12 14.6 21.97 11.4 11.54

HCAs required 9.8 11.16 5.4 6.01 7.8 8.15 9.7 9.43 7.6 10.52

Total FTEs required

32.6 29.06 13.6 21.35 25.9 30.28 24.3 31.39 19.1 22.06

**need to understand outpatient activity/Day cases *** need to review RCN guidance

45

APPENDIX 5: SNCT REVIEWS HELD BETWEEN MARCH AND APRIL 2019

W

AR

D

BE

DS

H

EA

D C

OU

NT

WT

E

C

UR

RE

NT

SK

ILLS

MIX

S

NC

T P

rop

ose

d m

ix

OC

CU

PA

NC

Y 1

2

MID

DA

Y (

Fe

b 2

01

9)

OC

CU

PA

NC

Y 1

2

MID

NIG

HT

(F

eb

20

19

)

CH

PP

D

(De

cem

be

r 2

01

8)

CU

RR

EN

T S

TA

FF

ING

LEV

ELS

P

RO

PO

SE

D S

TA

FF

ING

LEV

ELS

DIF

FE

RE

NC

E

Co

st

CO

MM

EN

TS

DPOW

RN Carer E L N RN Carer

Trust National E L N E L N

A1

Amethyst

23

17.02

13.57

67/33

67/33

50/50

17.8

11.9

113%

97%

5.52

7.28

4/2

4/2

2/2

4/2 (+CN)

4 /2

3 (T)/2

↑1.4wte RN ↑1.0 Carer

Twilight x 1 RN 7 days

per week/ CN

additional/Ward clerk

weekend cover review

AMU

26

24.68

18.85

63/37

63/37

57/43

20.7

13.8

85%

73%

-

-

5/3

(-CN)

5/3

4/3

5/3 (+CN)

5/3

5 (T)/3

↑1.4wte RN

↑1.0Carer


per week/ CN

additional in

clu

de

s

F &

Am

b

incl

ud

es

F &

Am

b

B2 SAU

20

+ 6

21

.01

(1

8.8

3

wa

rd)

17

.02

( 1

4.7

8

wa

rd)

50/50

50/50

60/40

23.7

15.8

87%

80%

7.2

(includes

SAU)

4/3

4/3

3/1

5/3

5/3

3/1

↑2.24wte

RN

X 1 RN 12 hours x 7

days per week

B3 HOBs

22 +6

24.05

(19.5 7)

13.7

50/50

50/50

50/50

20.4

13.6

108%

100%

5.97

6.97

3/4 (-

CN)

3/3

2/2

3/4 (+CN)

3/3

3 (T)/2

↑1.4wte RN ↑1.0Carer


per week/ CN

additional

B4

24

16.42

13.47

43/67

43/67

50/50

22.0

14.7

100%

100%

5.74

6.97

3/4 (-

CN)

¾

2/2

3/4 (+CN)

3/4

2/2



per week/ CN

additional

B6

22

13.73

13.47

43/67

50/50

50/50

17.3

11.5

95%

92%

5.43

7.11

3/4 (-

CN)

3/3

2/2

3/4 (+CN)

3/3

2/2



per week/ CN

additional

B7

22

14.45

14.18

50/50

50/50

50/50

19.5

13.0

89%

90%

5.56

7.11

3/4 (-

CN)

3/3

2/2

3/4 (+CN)

3/3

3 (T)/2



per week/ Carer

additional

C1 Glover

(CCU)

26

24.05

14.67

63/47

63/47

63/57 8

.8/1

9.3

5.9

/12

.8

99%

95%

3/1(2/1)

3/1

(2/1)

2/1

(2/1)

3/1(2/1)

3/1

(2/1)

2/1

(2/1)

Zero

Newly merged ward to

embed and review at

next SNCT review

46

C2

27

14.53

18.75

50/50

43/67

40/60

19.0

12.6

101%

101%

5.7

4/3

(+CN)

3/4

2/3

4/4

(+CN)

3/4

3(T)/2

↑1.4wte RN

↑1.0Carer


per week/ CN

additional

C5

24

14.94

15.88

50/50

50/50

50/50

19.0

12.7

102%

99%

5.12

6.47

4/4 (-

CN)

3/3

2/2

4/4 (+CN)

3/3

3 (T)/2

↑1.4wte RN

↑1.0 Carer


per week/ CN

additional

C6

24

15.25

15.95

50/50

50/50

50/50

18.6

12.4

101%

100%

5.63

6.11

4/4 (-

CN)

3/3

2/2

4/4 (+CN)

3/3

3 (T)/2

↑2.04wte

RN

↑1.0 Carer


per week/ weekend RN

LD 0.64wte/CN

additional

Stroke

25

14.4

19.84

44/66

47/63

40/60

21.1

14.1

99%

100%

5.98

7.17

4/4 (-

CN)

3/4

2/3

4/4

(+CN)3/4

3 (T)/3



per week/ weekend RN

LD 0.64wte/CN

additional

Laurel

17

17.09

11.16

60/40

60/40

60/40

22.8

9.8

101%

96%

5.50

3/2

3/2

3/2

3/2

3/2

3/2

Zero

To review TNA role/ CN

role for E/review clinic

activity

Rainforest

16

+2

20.96

8.15

80/20

80/20

80/20

18.1

7.8

86%

80%

5.70

4/1

4/1

4/1

4/1

4/1

4/1

Zero

To review band 2

housekeeper role

16

23

13.95

16.07

43/67

43/67

50/50

22.2

14.8

91%

92%

5.64

7.17

3/4 (-

CN)

3/4

2/2

4/4

3/4

(+CN)

3 (T)/3



per week/ Carer nights

7 days/CN additional

17

23

13.73

16.25

43/67

43/67

50/50

21.4

14.3

91%

92%

5.56

7.17

3/3

(+CN)

3/4

2/2

4/3 (+CN)

3/4

3 (T)/3



per week/ Carer nights

7 days/CN additional

18 14

10.8

8.82

60/40

50/50

67/33

8.9

10.8

117%

88%

6.20

7.63

3/2

2/2

2/1

3/2

2/2

2/1

Zero

Establishment ok

19

12

15.34

6.01

67/33

67/33

100/0

8.2

5.4

94%

73%

7.09

7.87

2/1

2/1

2/0

2/1

2/1

2/0

Zero

Need to review OPD

activity

22

23

+4

18.89

17.82

50/50

50/50

60/40

23.9

15.9

91%

92%

7.36

(includes HOBs)

6.47

3/3

3/3

2/2

4/3

3/3

2/2

↑2.24wte

RN

LD x 1 RN 7 days per

week/ Review HOBs

location

23

30

18.89

17.82

50/50

50/50

60/40

24.5

16.3

91%

91%

4.69

6.11

4/4

4/4

3/2

4/4

4/4

4/2

↑1.4wte RN


per week/ Consider

TNA

24

30

18.89

17.37

50/50

50/50

60/40

26.4

17.6

92%

90%

5.40

7.95

4/4

4/4

3/2

4/4

4/4

3 (T)/2

↑1.4wte RN

Twilight x 1 RN 7 days per week

25

24

15.29

15.2

43/57

43/57

50/50

19.2

12.8

89%

84%

8.29

7.14

3/4

3/3

2/2

4/3

3/3

3 (T)/2

↑1.4wte RN


per week/↑ RN E x 5

days for ward rounds

27 20

14.62

12.06

43/67

43/67

43/67

17.7 11.8

90%

84%

7.47

7.1

3/4

3/4

2/2

47

28

24

+4

23

.34

(17

.86

wa

rd)

21

.22

(1

5.7

5

wa

rd)

57/63

57/63

50/50

19.9

13.3

90%

84%

8.29

(includes

HOBs)

7.14

4/3

4/3

2/2

4/3

4/3

3/2

↑2.4 RN

Nights x 1 RN 7 days per

week

CCU

13

15.15

5.28

75/25

75/25

67/33

9.3

6.2

86%

84%

7.74

7.95

3/1

3/1

2/1

3/1

3/1

2/1

Uplift x1wte

5 to 6

Uplift band 5 to 6/

review PCPI RN role

CDU

22

24.69

15.82

63/37

63/37

67/33

22.7

15.1

88%

82%

-

-

5/3

5/3

4/2

5/3

5/3

5 (T)/2

↑1.4wte RN

Twilight x 1 RN 7 days per week/consider TNA

HASU 6

5.16

0

Stroke and

HASU

15

23.6

13.92

66/33

66/33

66/33

14.2

9.5

88%

85%

4/2

2/2

2/1

4/2

2/2

2/1

Zero

Review CN role/

separate HASU from

ward

Disney 18

22.24

9.43

75/25

75/25

75/25

14.6

9.7

76%

63%

11.81

12.31

3/1

3/1

3/1

3/1

3/1

3/1

Zero

No change

3 15 13.35 9.99 50/50 50/50 60/40 12.9 8.6 92% 89% 6.08 7.17 3/3 2/2 2/1 3/3 2/2 2/1 Zero

Review DVT clinics

6

15

13.2

4.27

67/33

67/33

100/0

7.3

4.9

64%

61%

5.99

7.11

2/1

2/1

2/0

2/1

2/1

2/0

Zero

No change

Neuro Unit

14

11.54

10.52

40/60

40/60

60/40

11.4

7.6

90%

89%

7.01

6.8

2/3

2/3

2/0

2/0

2/3

2/0

Uplift x 1wte

band 5 to 6

Uplift x 1 band 5 to

band 6/ change 10-6

shift to later or twilight

48

Appendix 6: Model Hospital Care Hours Per Patient Day Review – Review 27 June 2019 taken from Model Hospital Inpatient Adult Areas data from Dec 2018 & Apr 19

Ward

Classification as per

Model Hospital

Actual Classification

Trust

Combined

CHPPD - Dec

18

National

CHPPD -

Dec 18

Trust

Combined

CHPPD -

Apr 19

National

CHPPD -

Apr 19

Trust CHPPD

change Dec 18

vs Apr 19

Trust £

Cost per Care

hour - Dec 18

National cost per hour

£ - Dec 18

Comments

DPOW

Amethyst Medical Oncology Haematology / Oncology & rheumatology 5.52 7.25 5..81 7.33 up 36.29 24.52

AMU N/A N/A N/A N/A N/A N/A N/A N/A N/A Data not collected / submitted to model hospital

B2 SAU General Surgery Acute Surgical Unit 7.37 7.14 7.01 7.51 down 24.30 25.13

B3 General Surgery Surgery male & Female 5.97 7.14 6.38 7.51 up 24.01 25.13

B4 ENT Endocrine and Care of the Elderly 5.74 6.97 5.71 6.97 down 22.82 25.00

B6 Trauma & Ortho Orthopaedic Trauma 5.43 7.11 5.89 7.41 up 28.98 24.54

B7 Trauma & Ortho Elective Orthopaedic 5.56 7.11 6.23 7.41 up 25.52 24.54

C1 Kendall Cardiology Cardiology & General Medicine 4.82 7.83 5.01 8.14 up 23.93 26.48

C2 General medicine Endocrine / Care of the elderly / Diabetes 5.89 7.17 N/A N/A N/A 24.77 25.00 Data not available for April 19

C5 Resp Med Respiratory 5.12 6.47 5.49 6.74 up 23.95 24.51

C6 Gastro Gastro 5.63 6.11 6.26 6.14 up 22.88 24.16

CCU Cardiology Cardiology 8.65 7.95 8.97 8.14 up 25.95 26.48

Stroke General medicine Stroke 5.98 7.17 6.04 7.33 up 22.70 25.00

Rainforest Paediatrics Paediatrics 7.53 12.49 7.53 12.49 static 30.78 31.30

Laurel Gynaecology Gynaecology 6.09 8.22 6.09 8.22 static 30.88 27.52

SGH

16 General Medicine Elderly 5.64 7.17 5.67 7.33 up 23.92 25.00

17 General Medicine Elderly and Short Stay 5.56 7.17 5.67 7.33 up 25.11 25.00

18 Haematology Haematology and Oncology 6.20 7.63 N/A N/A N/A 34.47 27.69 Data not available for April 19

19 Gynaecology Gynaecology 7.09 7.87 7.35 8.22 up 33.22 27.52

22 Respiratory Med Respiratory and HOBs 7.36 6.47 7.12 6.74 down 27.32 24.51

23 Gastro Gastro 4.69 6.11 5.49 6.14 up 25.09 24.16

24 Cardiology Cardiology & Endocrine 5.59 7.95 5.38 8.14 down 24.81 26.48

25 General Surgery Surgery Female 8.29 7.14 8.06 7.51 down 23.32 25.13

26 Obstetrics Obstetrics 7.39 14.93 8.23 15.21 up 33.33 30.82

27 Trauma & Ortho Trauma & Ortho 7.46 7.10 N/A N/A N/A 27.30 24.47 Data not available for April 19

28 General Surgery Surgery Male and HOBs 5.39 7.14 5.25 7.51 down 27.29 25.13

CCU Cardiology Cardiology 7.74 7.95 9.17 8.14 up 25.68 26.48

CDU N/A N/A N/A N/A N/A N/A N/A N/A N/A Data not collected / submitted to model hospital

Stroke General Medicine Stroke 10.85 7.33 10.85 7.33 static 29.32 25.08 Need to review as includes HASU

Disney Paediatrics Paediatrics 11.81 12.31 11.00 12.49 down 31.67 31.46

GDH

3 General Medicine Medicine 6.08 7.17 6.86 7.33 up 27.60 25.00

6 Trauma & Ortho Surgery 5.99 7.11 7.15 7.41 up 33.91 24.54

Neuro Unit Rehabilitation Neuro 7.01 6.80 8.01 6.81 up N/A N/A

49

Appendix 7: Prospective and retrospective Rostering Process

50

Appendix 8: Staffing Incident review

Sitter issues, 2

↓RN (x2), 4

↓ HCA , 9

Nights, 35

HASU ↓RN, 1

ECC ↑acuity & activity, 6

Womens ↑acuity & activity ↓ MW, 9

HCA moved, 1 RNs moved, 1

2 RNs for 22-24 patients, 1 ITU ↑ patient number x 1, 0 Bank in charge,

2 RNs on A1, 1

1 subtantive RN, 1 NQN in

charge, 1 no substantive, 2

51

Appendix 9: Red Flags

Red Flags include:

• Delay in medicines rounds by 1 hour

• Delay in administration of IV medications by 1 hour to more than 3 patients

• Delay of more than 30 minutes to provide acute pain relief

• Less than 2 trained nurses on a clinical area

• Less than 50% substantive staff on a shift

• More than 50% of staff under 12 months qualified

• Trained nurse less than 12 months qualified, or sti ll in preceptorship left in charge.

52

Appendix 10 - Apprenticeship Summary Count of Role HCA/RSW Training Day Grand

Total

PCN

Trainin

g Day

Cost

(Backfill at band 2 HCA – per week)

Workplace Monday Tuesday Wed Thurs Friday HCA

backfill

PCN

backfill

Total Cost

of backfill

Amethyst 1 2 3 £246.00

AMU, DPoW 1 1 2 £164.00

Disney, SGH 1 2 3 £246.00

ECC, DPoW 3 2 1 6 £492.00

ECC, SGH 1 1 2 £164.00

Endoscopy, SGH 1 2 3 £246.00

Endoscopy, DPoW 1 1 £82.00

GDH 1 1 2 £164.00

HDU, DPoW 1 1 £82.00

Macmillan Healthcare 1 1 2 £164.00

Macmillan Healthcare 1 1 £82.00

MAU, DPoW 1 1 £82.00

Midwifery, SGH 1 1 £82.00

53

MIU, GDH 1 1 £82.00

NICU, DPoW 3 3 £246.00

NICU, SGH 2 2 £164.00

OPD, DPoW 1 1 2 £164.00

OPD, SGH 2 2 £164.00

Ophthalmology, GDH 1 1 2 £164.00

OT, SGH 1 1 £82.00

Pre Assessment,

DPoW

1 1

£82.00

Recovery, DPoW 1 1 £82.00

Stroke, DPoW 1 1 2 4 £328.00

Stroke, SGH 1 1 £82.00

Theatres General,

DPoW

1 1

£82.00

VAD 1 1 £82.00

Ward 19, SGH 1 1 2 £164.00

Ward 2, SGH 1 1 2 1 5 £410.00

Ward 22, SGH 1 2 3 6 £492.00

54

Ward 23, SGH 1 1 1 3 £246.00

Ward 24, SGH 1 1 2 £164.00

Ward 25, SGH 2 1 2 5 £410.00

Ward 27, SGH 1 1 £82.00

Ward 28, SGH 2 1 3 6 £492.00

Ward 4, GDH 3 3 £246.00

Ward B3 1 1 2 £164.00

Ward B6 1 1 2 £164.00

Ward B7 1 1 2 £164.00

Ward C2, DPoW 1 1 £82.00

Ward C5, DPoW 1 2 3 £246.00

Grand Total

23

17

23

17

13

93

13

£7,626.00

£1,066.00

£8,692.00

55

Appendix :11 The 15 Steps Quality Improvement Programme has undertaken reviews on the following areas:

Areas completed 15 Steps:-

Date of visit Area visited Overall Score

24 April 2019 Stroke DPOW Requires Improvement

01 May 2019 17 Requires Improvement

08 May 2019 25 Good


22 May 2019 B7 Requires Improvement


05 June 2019 B6 Intensive support

11 June 2019 NRC Requires Improvement

12 June 2019 C5 Requires Improvement

19 June 2019 23 Good

20 June 2019 Amethyst Intensive Support

2 July 2019 B3 Requires Improvement

3 July 2019 PIU Requires Improvement

10 July 2019 C6 Requires Improvement

56

Appendix 12: example of ward costs calculations

Amethyst

start

finish break mins

shift hrs

paid hrs

Total Hours

WTE Basic

WTE allow

OnCost £

Cost £ ENH

Cost £

Care Navigator

substantive

mon-fri

08.00

16.00

30

8.0

7.5

37.5

1.00

1.20

£25,500

£25,500

£30,600

Band 3 - Basic £20,795

Bank 0.07 £1,900

1.27 £32,500

Twilight shift

substantive

mon-sun

16.00

00.00

30

8.0

7.5

52.5

1.40

1.68

£33,751

£42,159

£70,800

Band 5 - Basic £27,260

Bank 0.10 £4,200

1.78 £75,000

3.05 £107,500

Assumptions days

Annual Leave: 31

Statutory Holidays: 8

Training: 5 20.3%

Bank - Sickness 4.1%

Bank - Other 1.5% 5.9%

Total Headroom 26.2%

Enhancement Percentage Rates Applicable Under A4C

57

Band

Night

Enhance %

Saturday Enhance

%

Sun/BH

Enhance %

1 48% 48% 95%

2 42% 42% 84%

3 35% 35% 70% 4plus 30% 30% 60%

Night Rate Paid From: 20:00

Night Rate Paid To: 06:00

Night Rate Applies to Full Shift If >50% of Shift Is at Night Rate

3 - Nursing Establishment Review · Establishment review for inpatient areas, excluding Maternity....

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