trust board meeting 9 october 2014 - west herts college · 2014-10-03 · trust board meeting 9...

Trust Board Meeting 9 October 2014

Title of the paper: Safe staffing – nursing and midwifery, bi-annual skills mix and month 3, 4 and 5 report

Agenda item: 334/21

Lead Executive: Tracy Carter, Chief Nurse & Director for Infection Prevention and Control

Author: Toni Nettleton, Lead Nurse Workforce

Trust objective: Tick as appropriate: Achieving continuous improvement in the quality of patient care that we provide and the delivery of service performance across all areas; Setting out our future clinical strategy through clinical leadership in

partnership and with whole system working; Creating a clear and credible long term financial strategy.

Purpose: To provide information and next steps following the establishment review of adult inpatient wards and an update on progress regarding the arrangements for managing safe nursing and midwifery staffing levels.

Previously discussed and date for further review:

Committee Date

Trust Leadership Executive Committee

25 September 2014

PSQR 2 October 2014

Benefits to patients and patient safety implications To assure we have sufficient qualified, skilled and experienced staff to meet patient care needs within our adult inpatient wards to give good quality care.

Risk implications for the Trust Patient safety and clinical care are likely to suffer as a consequence of not having the right staff with the right skills in the right place at the right time.

Mitigating actions (controls) Utilisation of bank and agency to maintain safe staffing levels. Implementation of a real time database and trust-wide sahred access for senior nurses to identify risks and manage nursing and midwifery levels on a day to day basis.

Links to Board Assurance Framework, CQC outcomes, statutory requirements The Care Quality Commission (CQC), under regulation10(3) of the Health and Social Care Act 2008 (Regulated activities) Regulation 2010

Legal implications

Financial implications

Recommendations To approve the proposed changes. To note month 3, 4 and 5 reports.

Agenda Item: 334/21

Trust Board – 09 October 2014 Safe staffing – nursing and midwifery, bi-annual skills mix Presented by: Tracey Carter Chief Nurse and DIPC

1. Purpose 1.1 This paper presents the outcome of the establishment review of adult in-patient

wards to determine if the nurse staffing levels within in-patient adult wards have sufficient qualified, skilled and experienced staff to meet patient care needs.

1.2 To provide an update regarding the arrangements for managing safe nursing and midwifery staffing levels within the inpatient wards.

2. Background 2.1 Since the publication of the report from the Mid-Staffordshire NHS foundation Trust public inquiry (2003), the review of increased Mortality rates in 14 trusts by Bruce Keogh (2013) and Don Berwick’s review into patient safety (2013), risks to patients were highlighted where organisations had not taken seriously when it had been identified that the right people with the right skills at the right place and time were not in place. 2.2 Collectively the National Quality Board, Chief Nursing Officer England along with experts have now set out clear expectations of NHS providers and commissioners through the paper ‘How to ensure the right people with the right skills, are in the right place at the right time’ (2013). 2.3 The Care Quality Commission (CQC), under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, ask that Trusts are assured that there are sufficient numbers and mix of staff on duty to provide the best and safest care to the people using the hospital. See appendix 1- 3 for Nursing and Midwifery safe staffing papers for June July and August. 2.4 A previous review of adult inpatient areas was undertaken across West Hertfordshire Hospital Trust (WHHT) in May 2013. The review utilised the following tools and benchmarks:

Patient Dependency tool that benchmarks best practice wards in the UK covering 28 clinical specialities by Keith Hurst - evidence based tool.

Professional Judgement and scrutiny to interpret results that takes into account local context and patient needs including ward layout and design.

Best practice recommendations were utilised in areas where the patient dependency tool was not specific e.g stroke units, high dependency units.

All results were triangulated and reflected the totality of Registered Nurses and support staff.

Results were also benchmarked against the Royal College of Nursing (RCN) minimum recommendation of 1:7 nurse to patient ratio and trained to untrained skill mix. See appendix 4 for explanation of nurse to bed and staff to bed ratios and current ratios within our adult in patient wards.

2.5 As recommended in the report from the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) each ward has 37.5hrs of Band 7 acting in a supervisory capacity to enable nurse leadership except in emergencies, as part of the nursing provision on the ward. 2.6 Between June 23rd and July 11th 2014 the Chief Nurse led a further review of adult ward based nursing establishments supported by the Lead Nurse for workforce in partnership with the divisional heads of nursing. National Institute for Health and Care Excellence (NICE 2014) recommend that several models are used when undertaking establishment reviews to provide balanced assurance and the results are triangulated. This review has also included the Safer Nursing Care Tool (SNCT) which was not used in the previous establishment review. The NHS institute of innovation and improvement deemed the SNCT not fit for purpose in 2013 but it has now been revised and re-launched and deemed appropriate for use as an evidence based tool. A summary of outputs can be found in appendix 5 and strengths and limitations of tools utilised in appendix 6. 2.7 Following the establishment review NICE published its guidance for safe staffing in adult inpatient wards in acute hospitals and made a number of recommendations in relation to organisational strategy, principles for determining nurse staffing requirements, setting the ward nursing staff establishments, monitoring and evaluating ward nursing staff establishments. NICE also comment there is evidence of increased risk of harm when a registered nurse is caring for more than 8 patients during a day shift; this guidance was also considered within the review. NICE also recommend each ward should determine the requirements for nursing staff to ensure safe patient care and there is no single nursing staff to patient ratio that can be applied across the whole range of wards.

3. Analysis/Discussion 3.1 The data sheets were reviewed by Lead Nurse for workforce with the Heads of Nursing. The multipliers for SNCT (Appendix 7) and dependency benchmarks (Appendix 8) were adjusted to reflect the 21.6% uplift applied at WHHT. An assumption of 100% occupancy was incorporated into the analysis with any blanks scoring zero as staff did not capture patients pending arrival to the ward following discharges. Exclusions were also made for escalation areas (i.e Acute Stroke Unit gym) and supervisory band 7 roles. 3.2 All band 7s and Matrons were consulted and proactively contributed to their clinical areas under review as indicated in the NICE principals for determining and setting ward establishments. The results were scrutinised and challenged by the heads of nursing and the Chief Nurse.

Surgery and Gynaecology wards 3.3 The triangulated variance across Surgical and Gynaecology wards was -0.77wte. This indicated that the Nursing establishment across surgery and Gynaecology is currently safe. All wards that have a higher nurse to bed ratio at night have elective capacity and were professionally judged as appropriate for the case mix. 3.4 It is recommended that the division review opportunities to move staff across wards in response to the review outcomes. Care of Older people wards and Dual Frailty Unit 3.5 The current SNCT is being revised for use within older people’s wards and we are awaiting the outcome. The triangulated variances across the two care of older peoples wards Sarratt and Croxley was 5.53wte. 3.6 These areas showed a significant variance in results in one of the models. The dependency model is based on activities of daily living data that may not be reflective of the real dependency of the patients in these wards. This is recognised as a weakness of the tool. Further analysis will be undertaken in October 2014 to reassess the acuity and dependency of our older people’s wards and consider options to merge the nursing workforce across both wards to maximise efficiencies. Both wards currently meet all the RCN safe staffing minimum recommendations to deliver care to older people of 1:7 nurse to bed ratio, 50/50 skill mix and staff to bed ratio of 3.2 – 3.8. 3.7 There is currently no guidance or benchmarks for staffing ratios or skill mix for the new Dual Frailty Unit. The unit cares for older people with complex needs and has been professionally judged to be suitably staffed to safely care for patients with complex care needs. General Medical wards 3.8 The triangulated variance for Winyard ward was 3.5wte and Red Suite 2.68wte. These are both small 18 bedded wards. The current registered nurse to bed ratio on days in both areas is 1:6 the staff to bed ratio is 1:4. On nights the nurse to bed ratio is 1:6 on both wards, but the staff to bed ratio is 1:5 on Red Suite and 1:4 on Winyard ward. Professional judgement has taken into account the size, layout and location of these units within the main hospital and has deemed current levels of staffing appropriate to maintain patient and staff safety day and night within these areas. The current nurse and staff to bed ratios are in line with other acute medical wards within the Trust. Specialist medical wards

3.9 The triangulated variance across the medical specialty wards was 1.60wte, this indicated the Nursing establishment is currently safe. Heronsgate ward in 2 models indicates they require an increase to their current establishment however a regular review of this area will continue to monitor fluctuations or changes to acuity and dependency over time before any adjustment is made.

Acute Assessment Unit (AAU) Level 1 3.10 The AAU has a total of 45 beds, 18 of which are monitored and 9 are unsighted cubicles away from the main clinical ward areas. The triangulated variance for AAU L1 is 6.61wte. Whilst the model triangulation indicated that there is a variance of between 1.87 and 2.49wte within each ward, professional judgement has taken into account layout and design of the areas and has deemed current levels of staffing appropriate to maintain patient safety day and night within the current bed configuration. 3.11 As part of the unscheduled care work stream AAU level 1 will be changing its focus to improve patient flow, pathways and efficiency. Within this project discussions on the re-configuration of beds and the potential merger of clinical areas to maximise flexibility and efficiencies within the current nursing workforce are taking place. Acute Assessment Unit (AAU) Level 3 and Cardiac care unit (CCU) 3.12 The total triangulated variance for the three clinical areas within L3 of the AAU; Green and Purple, Blue and Yellow was 17.87wte. 3.13 All areas in AAU level 3 were professionally judged to currently have the appropriate level of staff in place to deliver safe care to patients due to the current bed configuration including a 6 bedded isolation area, 12 cardiac monitored beds and 6 unsighted cubicles that are all away from the main bays of each ward. The CCU has 11 monitored beds and a triangulated variance of 2.24wte. 3.14 A re- configuration of AAU Level 3 has been proposed that includes the relocation of the CCU to AAU Level 3 with 24 monitored beds to reflect changes in patient pathways, resulting in an improved patient experience. This change will improve efficiency across the areas allowing a reduction of 5.67wte posts with a predicted saving of £267,000 over 12 months (See appendix 9) Aldenham Ward 3.12 Aldenham ward is comprised of 21 respiratory beds and a 6 bedded high dependency unit (HDU). The triangulated variance was 4.22wte.The HDU is funded to provide level 2 care for a designated cohort of patients, however the 3 week audit indicated a reduced number of level 2 admissions than expected. As a result the recommended establishment was less than the funded establishment. 3.13 Based on current acuity and dependency evidence it is proposed to reduce the trained nursing planned hours by 11.5 a day (2.61wte trained nurses). It should be noted that the acuity and dependency may not be reflective of the autumn, winter and spring seasons within this respiratory ward and therefore the ward will be closely monitored on a daily basis over the coming months. 3.14 If further reviews indicate that demand remains lower than anticipated, the Trust should consider options for further reconfiguration of the bed base.

4. SUMMARY 4.1 The review utilised three tools to agree safe staffing levels. In light of the strengths and weaknesses of the tools, professional judgement and scrutiny was applied to provide a balanced assurance. The paper ‘How to ensure the right people with the right skills are in the right place at the right time’ (2013) is clear that using tools are only one approach to making decisions on staffing and that professional judgement and scrutiny are critical when evaluating tool results to ensure decisions are based on patient care needs and knowledge of the local context. The overall triangulated variance from the three tools was 49.79wte. Based on acuity and dependency outputs, proposed bed re-configurations and professional judgement and scrutiny of the results a further 8.28wte were reduced from the initial overall variance. 4.2 The summary of findings indicates that overall our clinical adult inpatient wards have sufficient nursing staff on a shift by shift, day by day basis to safely care for patients. 4.3 The nurse to patient ratio in all clinical areas is currently a minimum of 1:7 on days and meets the minimum RCN recommendations. 4.4 At night the nurse to patient ratio is a minimum of 1:8 with the exception of 3 clinical wards within surgery whose nurse to patient range was between 1:9 and 1:10, theses areas have an elective case mix and were professionally judged as appropriate.

4.5 The RCN recommends a 65/35 - 70/30 trained to untrained skill mix and 50/50 - 65/35 in older peoples wards. Of the twenty four clinical areas reviewed, eight fell below this benchmark. This parameter however should not be looked at in isolation to assess safe staffing but should be seen in conjunction with other parameters such as the nurse and staff to bed ratios.

5. Next steps

5.1 As recommended a review of ward establishments should be undertaken on a biannual basis as a minimum and presented to the Trust Board. Acuity and dependency reviews should be carried out a minimum of 3 times a year to capture seasonal variances. 5.2 To discuss the development of a daily acuity and dependency measurement tool across our inpatient ward areas. 5.3 A profile of the experience and capability of the substantive workforce should be undertaken to inform future reviews including vacancies, agency usage and staff turnover. 5.4 Further opportunities to merge or re-configure should be considered for small wards/units to optimise efficiency and flexibility of the nursing workforce. 5.5 Senior nurse coverage at Band 7 and 6 should be profiled and benchmarked to achieve equity across all in patient clinical areas.

5.6 To carry out a detailed review of ward budgets to determine and agree the distribution and recruitment of uplift required to support sickness, annual leave and study leave. Some clinical areas are noted to have recruited to the full 21.6% budget uplift which impacts on their ability to flexibly utilise the nursing workforce. 5.7 A full review and profile of unregistered clinical roles should be undertaken across all clinical areas to inform and support the development of an unregistered workforce strategy. 5.8 To continue the development of an integrated performance report that will be owned by the ward managers and senior nursing divisional teams. The report will include both quality and workforce metrics for example monthly data on falls, pressure ulcers, test your care and I want great care, sickness/absence, and vacancies. This will assist in measuring the safety and patient experience within our wards and provide further ward to board assurance. 5.9 Review specials and escort use and investigate options for a pool to be developed with specialist skills and reduce temporary usage. 5.10 Complete SNCT and dependency tools again in October 2014. 5.11 Review and present papers on Maternity and children’s skill mix and establishments by December 2014.

6. Recommendations 6.1 The committee is asked to approve the proposed changes. Tracey Carter Chief Nurse 15th September 2014

Appendix 1

Nursing and Midwifery Safe Staffing - month 3

1. Purpose 1.1 This paper provides an update on the progress regarding the arrangements within the Trust for managing safe nursing and midwifery staffing levels within the inpatient ward.

2. Background

2.1 It is now a national requirement for all hospitals to publish information about staffing levels on wards, including the percentage of shifts meeting their agreed staffing levels. This initiative is part of the NHS response to the Francis report which called for greater openness and transparency in the health service.

2.2 A Nursing and Midwifery safe staffing paper was presented to the Trust Board in July 2014 in response to the National Quality Board guidance in ensuring compliance and commitment to the 10 expectations and recommendations, CQC compassion in practice and recent National reports Mid Staffordshire Public Enquiry, Keogh and Cavendish reviews and the Berwick safety report.

3. Analysis/Discussion 3.1 The Trust submitted all unify data to NHS England as required by the 10th July 2014 this will be available to view on NHS Choices website on or around the 24th July allowing patients and the public to see how hospitals are performing. See appendix 1 for June 2014 unify data by site and ward. Overall the Trust saw a decrease in the percentage of filled hours against planned in June. Over 33 wards/areas, this equated to 1,117 hrs unfilled hours for trained staff and 254 hours for health care assistants on day shifts. On night shifts 414 hours were unfilled for trained nurses/midwives against the planned hours required on duty, for healthcare assistant 58 hours were on duty above planned hours.

All shifts day and night are professionally judged by the nurse in charge of the clinical area for safety by RAG rating. Mitigations to maintain safe staffing were put in place where risks were highlighted and concerns escalated in accordance with the Nursing and Midwifery safe staffing escalation policy. It is important to note that actual staffing levels submitted via the unify return comprise all staff on duty including staff that were unplanned for trained and healthcare assistants e.g 1:1 specials, escorts. This in turn would distort the actual levels of staff required on duty to deliver safe patient care as these are essential staff and would be above the required agreed planned hours.

http://www.midstaffspublicinquiry.com/home

The data therefore should not be looked at in isolation but be considered in line with the shift RAG ratings exception report. See tables 1–3 below for the comparison data and trends overall in the trust and then by hospital. Table 1 – West Hertfordshire Hospitals overall percentage of filled against unplanned hours

Table 2 – St Albans City Hospital percentage of hours filled against unplanned

Table 3 – Watford General Hospital percentage of hours filled against planned

Monthly comparison data and trends of the percentage of filled hours against planned by division is shown in tables 4–6 below.

May June July AugustSeptemb

erOctober

November

December

January February March April

Trained Nurses/Midwives Day 100.8% 97.9%

Trained Nurses/Midwives Night 99.0% 99.1%

Health CareAssistants Day 99.8% 99.0%

Health Care Assistants Night 108.2% 100.3%

Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e

West Herts Trust Overall


erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e

St Albans City Hospital


erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e

Watford General Hospital

Table 4 - Medicine percentage of filled hours against planned

Table 5 – Surgery percentage of hours filled hours against planned

Table 6 - Womens and Childrens percentage of filled hours against planned

Some clinical areas are noted to have an increase in hours above planned for health care assistants due to fluctuations in the acuity or dependency of patients on some shifts e.g 1:1 specials, additional hours were required to maintain patient safety and would be above the planned requirements of the daily staffing agreed. 3.2 Across all ward and departments there were 2,322 day and night shifts 2,215 shifts were rated green, 106 rated amber and 0 shifts were rated red in June 2014. See appendix 2 for monthly detail by ward/department that incorporates areas not included in the unify data reporting.


erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e

Medicine


erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rgae

Fill

Rat

e

Surgery


erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e

Womens & Childrens

The trust overall saw an increase in amber RAG rates during the month of June. Shifts rated amber rose by 2.6% from the previous month. See table 1 below. Table 1 - West Hertfordshire Trust overall percentage shift RAG rating.

All divisions reported an rise in amber rated shifts, 1% in medicine, 0.4% in surgery and 8% in the division of women’s and children from the previous month, see tables 2-4 below for comparison data. Table 2 - Medicine monthly percentage shift RAG rating

Table 3 - Surgery monthly percentage shift RAG rating

May June July AugustSeptembe

rOctober

November

December


Green 98.0% 95.4%

Amber 2.0% 4.6%

Red 0.0% 0.0%

Target RAG 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%100.0%

RA

G P

erc

enta

ge



rOctober

November

December


Green 99.0% 98.0%

Amber 1.0% 2.0%

Red 0.0% 0.0%

Target RAG 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

RA

G P

erc

enta

ge

Medicine


rOctober

November

December


Green 99.0% 98.6%

Amber 1.0% 1.4%

Red 0.0% 0.0%

Target RAG 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

RA

G P

erc

enta

ge

Surgery

Table 4 – Women and children’s monthly percentage shift RAG rating

All areas who rated amber on a day or night shift took action to mitigate any risks to maintain patient safety. Appendix 3 provides the detail for the safe staffing exception report for June 2014, by division and ward, with mitigations to maintain safe staffing on the amber rated days. 3.3 The establishment reviews for in-patient clinical areas and will be presented to the trust board in September 2014.

4. Risks 4.1 Managing unexpected fluctuations in patient acuity and dependency both during shifts and out of hours that require a higher level of staff than the agreed daily requirement. 4.2 Surge areas that are opened in response to fluctuations in patient activity are at risk of not having the appropriate safe staffing due to dependency on temporary staff. 4.3 Data is currently sourced from both electronic and manual data entry to enable ratification of robust data collection. User error and administrative failure pose a risk to accurate data gathering and assurance.

5. Recommendations 5.1 The committee is asked to:

Note the information and assurance

Note the ongoing work and actions

Jackie Ardley Chief Nurse 16th July 2014


rOctober

November

December


Green 95.0% 87.0%

Amber 5.0% 13.0%

Red 0.0% 0.0%

Target RAG 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%R

AG

Pe

rcen

tage

Womens and Childrens

Appendix A West Hertfordshire Hospitals Unify Fill rate indicator return Staffing: Nursing, midwifery and care staff June 2014

Day Night

Registered midwives/nurses

Care Staff


Care Staff Day Night

Site Code

Site Name

Total monthly planned staff hours

Total monthly actual staff hours







Average fill rate - registered nurses/midwives (%)

Average fill rate - care staff (%)



RWG03

St Albans City Hospital 1927 1997.5 852.5 867 1104 1115.5 345 310.5

103.7% 101.7% 101.0% 90.0%

RWG02

Watford General Hospital 51432 50245 25268.5 25000 44114 43688.5 17905.5 17997.5

97.7% 98.9% 99.0% 100.5%

West Hertfordshire Hospitals Unify Fill rate indicator return by ward

Day Night Day Night

Hospital Site Details

Ward name

Main 2 Specialties on each ward Registered midwives/nurses Care Staff Registered midwives/nurses Care Staff Average fill rate - registered nurses/midwives (%)




Hospital Site name Specialty 1 Specialty 2









RWG02 Watford General Hospital - RWG02

AAU Blue Level 1 300 - GENERAL MEDICINE

1155 1147.5 690 667 1035 989 690 713 99.4% 96.7% 95.6% 103.3%


AAU Yellow Level 1 300 - GENERAL MEDICINE 1170 1181.5 690 793.5 1035 1035 690 759 101.0% 115.0% 100.0% 110.0%


AAU Green Level 1 300 - GENERAL MEDICINE 1177.5 1193 690 690 1035 1035 690 690 101.3% 100.0% 100.0% 100.0%


AAU Red Suite 300 - GENERAL MEDICINE 1192.5 1177.5 690 678.5 1035 1012 345 345 98.7% 98.3% 97.8% 100.0%


AAU Triage Level 1 300 - GENERAL MEDICINE 1968 1795.5 859 962.5 1035 1012 690 713 91.2% 112.0% 97.8% 103.3%


AAU Blue Level 3 300 - GENERAL MEDICINE 1440 1302 1035 1023.5 1380 1345.5 690 713 90.4% 98.9% 97.5% 103.3%


AAU Yellow Level 3 300 - GENERAL MEDICINE 1177.5 1128 690 632.5 1035 1000.5 345 356.5 95.8% 91.7% 96.7% 103.3%


AAU Green & Purple Level 3

300 - GENERAL MEDICINE 1764 1737 1380 1276.5 1380 1357 690 667 98.5% 92.5% 98.3% 96.7%


Bluebell 430 - GERIATRIC MEDICINE 1537.5 1526 1380 1334 1380 1357 1380 1403 99.3% 96.7% 98.3% 101.7%


Winyard 430 - GERIATRIC MEDICINE 1192.5 1158.5 690 686 1035 954.5 690 667 97.1% 99.4% 92.2% 96.7%


Sarratt 430 - GERIATRIC MEDICINE 1882.5 1994 1380 1744 1725 1725 1035 1322.5 105.9% 126.4% 100.0% 127.8%


Croxley 430 - GERIATRIC MEDICINE 1537.5 1476 1035 1184.5 1380 1380 1035 851 96.0% 114.4% 100.0% 82.2%


Coronary Care Unit (CCU) 320 - CARDIOLOGY 1605 1515 241.5 230 1380 1380 0 0 94.4% 95.2% 100.0% #DIV/0!


Cassio 300 - GENERAL MEDICINE 1192.5 1189 690 989 1035 1035 345 655.5 99.7% 143.3% 100.0% 190.0%


Gade 370 - MEDICAL ONCOLOGY 1192.5 1139.5 690 667 1035 1035 0 126.5 95.6% 96.7% 100.0% #DIV/0!


Heronsgate 300 - GENERAL MEDICINE 1192.5 1216 782 705 1035 1035 345 345 102.0% 90.2% 100.0% 100.0%


Aldenham 300 - GENERAL MEDICINE 2227.5 2151 1035 1012 2070 2047 345 391 96.6% 97.8% 98.9% 113.3%


Acute Stroke Unit Watford 300 - GENERAL MEDICINE 2572.5 2515 1260 1337 2415 2415 1035 1104 97.8% 106.1% 100.0% 106.7%

RWG03 St Albans City Hospital - RWG03

De La Mare/Beckett 100 - GENERAL SURGERY 1927 1997.5 852.5 867 1104 1115.5 345 310.5 103.7% 101.7% 101.0% 90.0%


Letchmore 100 - GENERAL SURGERY 1192.5 1154 690 701.5 1035 1023.5 345 345 96.8% 101.7% 98.9% 100.0%


Ridge 100 - GENERAL SURGERY 1537.5 1542 1035 885.5 1035 1012 690 644 100.3% 85.6% 97.8% 93.3%


Flaunden 100 - GENERAL SURGERY 1537.5 1537.5 1035 1012 1380 1345.5 345 391 100.0% 97.8% 97.5% 113.3%


Cleves 100 - GENERAL SURGERY 1192.5 1153.5 1035 959.5 1035 989 345 437 96.7% 92.7% 95.6% 126.7%


Langley 100 - GENERAL SURGERY 1089 1058.5 448.5 570 690 667 345 333.5 97.2% 127.1% 96.7% 96.7%


Combined ITU 192 - CRITICAL CARE MEDICINE

5163.5 5163.5 333.5 345 5129 5129 333.5 310.5 100.0% 103.4% 100.0% 93.1%


Starfish 321 - PAEDIATRIC CARDIOLOGY

1276.5 1290.5 345 295 1023.5 977.5 345 264.5 101.1% 85.5% 95.5% 76.7%


SCBU 321 - PAEDIATRIC CARDIOLOGY

2116 2395.5 989 736 2081.5 2254 1012 828 113.2% 74.4% 108.3% 81.8%


Elizabeth Ward 502 - GYNAECOLOGY 1537.5 1552.5 690 674 1035 1046.5 690 632.5 101.0% 97.7% 101.1% 91.7%


Delivery Suite 501 - OBSTETRICS 3487.5 3236 690 580 3105 3024.5 690 552 92.8% 84.1% 97.4% 80.0%


ABC 501 - OBSTETRICS 1260 1071 345 324 1035 1035 345 287.5 85.0% 93.9% 100.0% 83.3%


Victoria 501 - OBSTETRICS 915 757 345 306.5 690 655.5 345 287.5 82.7% 88.8% 95.0% 83.3%


Katherine 501 - OBSTETRICS 1605 1446.5 1035 699.5 1035 1035 690 563.5 90.1% 67.6% 100.0% 81.7%


Knutsford 501 - OBSTETRICS 345 345 345 299 345 345 345 299 100.0% 86.7% 100.0% 86.7%

Appendix B Number of day and night shifts (includes long days early and late shifts) planned against actual on duty.

Please note the actual staff on duty would include staff unplanned but essential to maintain patient safety e.g. 1:1 specials and staff rostered and working clinically on a period of supervision (orientation). These staff would be in addition to the planned staffing levels and distort the actual required staffing levels

Division Area

No. of Day Shifts

No. of Night Shifts

No. of Day Shifts

No. of Night Shifts

Planned Actual Planned Actual Planned Actual Planned Actual

Registered Nurses/Midwives Healthcare Assistants

Medicine

AAU Blue Level 1 106 105 90 88 60 64 60 62

AAU Yellow Level 1 108 110 90 90 60 69 60 66

AAU Green Level 1 109 111 90 91 60 60 60 60

AAU Red Suite 111 115 90 90 60 59 30 30

AAU Triage 176 161 90 88 82 91 60 62

AAU Blue Level 3 127 127 120 119 90 89 60 62

AAU Yellow Level 3 109 113 90 86 60 56 30 31

AAU Green & Purple L3 160 178 120 120 120 118 60 58

Bluebell 141 151 120 119 120 129 120 123

Winyard 111 118 90 89 60 60 60 60

A&E 300 294 300 298 120 108 60 58

UCC Hemel 90 89 60 60 30 29 0 0

MIU SACH 60 60 0 0 0 0 0 0

Sarratt 171 190 150 150 150 156 90 115

Croxley 141 136 120 120 120 105 90 74

CCU 147 140 120 120 21 20 0 0

Cassio 111 110 90 90 60 86 30 57

Gade 111 107 90 90 60 58 0 11

Heronsgate 111 113 90 90 68 64 30 30

Aldenham 201 194 180 179 90 97 30 34

Acute Stroke Unit 231 231 210 211 90 126 90 96

Total 2932 2953 2400 2388 1581 1644 1020 1089

Division Area

No. of Day Shifts

No. of Night Shifts

No. of Day Shifts

No. of Night Shifts



Surgery

Beckett 37 37 6 6 19 19 0 0

De La Mare 141 158 90 92 60 77 30 28

Letchmore 111 108 90 89 60 61 30 30

Flaunden 141 141 120 117 90 88 30 34

Ridge 141 151 90 88 90 77 60 56

Cleves 111 109 90 86 90 89 30 38

Langley 102 109 60 60 39 52 30 30

Combined ITU 449 449 446 446 29 30 29 27

Total 1233 1262 992 984 477 493 239 243

Wo

me

n's

& C

hild

ren

s

Paediatrics

Starfish 111 116 89 85 30 29 30 23

CED 120 125 90 79 0 2 0 0

Safari Day Unit 42 70 0 0 16 16 0 0

Neonatal Unit 182 203 181 196 29 21 29 23

Transitional Care Unit 2 11 0 0 57 43 59 49

Gynaecology Elizabeth 141 161 90 91 60 60 60 55

Maternity

Delivery Suite 321 335 270 263 60 63 60 48

Alexandra BC 120 118 90 90 30 34 30 25

Victoria 90 87 60 58 30 33 30 26

Katherine 150 158 90 90 90 70 60 49

Knutsford 30 30 30 30 30 26 30 26

Total 1309 1414 990 982 432 397 388 324

Appendix C June 2014 Trust safe staffing exception report

Nursing & Midwifery Professional Judgement safe staffing RAG Rates

Green - Staffing numbers are as expected on the rota and ward is assessed as being safely staffed taking into consideration workload and patient acuity. Staffing numbers are not as expected

but safe according to current workload.

Amber - Staffing numbers are not as expected and minor adjustments need to be made to bring staffing to a reasonable level given workload and acuity or staffing numbers are as expected

but given workload and acuity additional staff are required.

Red - Staffing levels inadequate to cope with current patient needs.

Division Area Date Shift Professional Judgement Rag Rating

Comments, Mitigation - Actions Taken to Ensure Safe Staffing Levels

Me

dic

ine

AAU Blue Level 1

02/06/2014 Day A Supervisory covering Early.

08/06/2014 Day A Trained nurse sent home due to sickness @10.00 .Both band 6 to work with each Hca.

09/06/2014 Day A Supervisory to be counted on numbers.

AAU Blue Level 3

13/06/2014 Day A supervisory in numbers.

AAU Green L1

29/06/2014 Night A Had to move an RN to cath lab as open to 12 patient. Will be supported clinically by AAU L1 Blue, Yellow & Purple.

AAU Red Suite

30/06/2014 Day A 1 RN off sick. Supervisory in numbers.

AAU Yellow Level 1

02/06/2014 Day A Supervisory working in numbers. RN shift not covered.

14/06/2014 Day A 1 csw shift for specialing is not covered.

30/06/2014 Day A supervisory working in numbers.

Bluebell 27/06/2014 Day A CSW to special has cancelled for long day. Have a CSW for night shift to special. Supervisory in numbers to support.

A&E

07/06/2014 Day A Short by one ENP day shift- however 2 x ANPs on duty.

08/06/2014 Night A No ANP at night.

14/06/2014 Day A Day ENP worked 07:15-17:00. No senior A&E doctor cover at night. Senior manager on-call (JA) advised that department have a night ENP service. Senior nurse on shift ENPed.

17/06/2014 Day A 2 senior nurses off sick , shifts out to NHSP, pulled 1 ENP as skill mix of concern. However the department is unsafe at present due to the skills required, remaining staff very junior.Nurse redeployed to support. Lead nurse supporting.

UCC Hemel 20/06/2014 Day A Anp sent from AE .

Acute Stroke

Unit

25/06/2014 Day A 1 staff phoned in sick, 1 staff carers leave 3 patients in the stoke gym shifts out to NHSP. Not filled.

30/06/2014 Day A 2 RN's overseas nurses - With no PIN number supporting on LD.

Croxley

14/06/2014 Day A 1 RN short due to late sickness. Escalated to senior nurse. No spare staff available. NHSP shift times amended. Own staff contacted to see if they could cover. Allocated to ensure that risk to patient safety minimised. Worked closely with Sarratt ward to ensure 1:8 ratio was maintained.

28/06/2014 Day A 1 bank staff nurse LD cancelled, escalated to senior sister on call. Requested wit ammended start time. Moved staff from Sarratt to maintain patient safety.2 bank nurses on the night are substantive staff.

Gade 04/06/2014 Day A HCA short on long day. Supervisory in the numbers to support.

05/06/2014 Day A LD short by one HCA. Senior Sister will cover AM shift

14/06/2014 Day A Sister on call informed no staff available

21/06/2014 Day A Moved staff to Heronsgate to cover there as they were short staffed.

27/06/2014 Day A we are 1 RN down. Shift was requested yesterday. Supervisory in numbers to support.

28/06/2014 Day A Bank nurse cancelled at the last minute. Bed manager informed no other staff available.

Surg

ery

Letchmore

28/06/2014 Night A One R.N short for the night shift. Multiple patient moves made off the ward over night, further increasing the work load. Bed manager and Bleep holder made aware at start of shift, additional staff requested however none available. Flaunden ward provided support with iv's

30/06/2014 Night A 1 HCA not covered for LD, start time changed to 10.00hrs on NHSP system. Senior Nurse did not arrive for night shift. Only two juniors on ward, Poor skill mix, plus increased work load. Bed managers + Bleep holders made aware. Senior nurse from ward next door will help out.

Wo

me

ns

& C

hild

ren

s

CED

02/06/2014 Day A Band 7 will cover as required.

05/06/2014 Night A Was covered but bank nurse off sick. Still trying to cover. Senior Sister is on call and can return if patient safety issue.

06/06/2014 Day A x1 night staff finishing at 07.00 so short for final hour. Starfish to support if required.

07/06/2014 Day A 1 member of staff on a 1-6pm in the day. Senior sister on call will come in should any issue to patient safety arise. A&E aware of situation.

07/06/2014 Night A 1 on night shift didn’t start till 9.30pm. Senior sister on call will come in should any issue to patient safety arise. A&E aware of situation.

10/06/2014 Day A Senior sister not supervisory

11/06/2014 Day A Will be covered by senior sister

14/06/2014 Night A Agency not filled. Staff on day worked 1400 -0230am to mitigate risk. A&E and Starfish aware, will support.

15/06/2014 Night A out to agency -not filled. Staff on MLD worked 1400 -0230am. A&E and Starfish aware, will support if required.

19/06/2014 Day A Will move nurses around ther service as required according to activity. Senior sister already clinical.

30/06/2014 Night A Night short after 04.30. A&E and Starfish aware, will support if required

Neonatal Unit

01/06/2014 Day A total 14 babies on SCBU. Unit was safe as there were no admissions

Starfish

12/06/2014 Day A 2 students, 1 3rd year plus help from Safari.

15/06/2014 Night A shift out to agency who were unable to cover. Dependency of patients high. CED staff available and are able to assist if needed. Senior nurse on call and are aware of the situation, available for advice by telephone where needed.

16/06/2014 Day A Supervisory band 7 avaliable to assist on ward. Patient dependency high. Shift out to agency

17/06/2014 Day A CSW shift out to agency. Band 7 avaliable to assist if needed

25/06/2014 Night A One trained member off staff short. Band 7 avaliable to assist if needed Night= Increased activity+admissions overnight , agency nurse did not have skills suitable for the ward. CED aware and are able to assist if needed. Senior nurse on call available.

Elizabeth

07/06/2014 Day A Bank worker RGN cancelled shift long day. Currently have one pt who needs ITU bed but none available (patient to be monitored hourly). Also have a patient booked for medical management today. Bed manager informed. No cover found. Staff split into 2 bays each and nurse in charge managed the medical management and the ITU patient.

07/06/2014 Night A Currently have one pt who needs ITU bed but none available (patient to be monitored hourly). Also have a patient booked for medical management today. Bed manager informed. No cover found. Staff split into 2 bays each and nurse in charge managed the medical management and the ITU patient.

13/06/2014 Day A Matron informed of staff shortage & would raise this at the meeting. No Supervisory to pull, no extra staff available to support. Request to Maternity for HCA for this aftenoon - evening to support and shift times changed on NHSP to start at 1300hrs. There are no Electives today but there are 4 Gynae patients in AAU and 1 in ITU requiring repatriation. The ward is safe but busy.

14/06/2014 Night A Hca sick for night duty, bed managers informed & would send someone if they can

15/06/2014 Night A Short of 1 hca tonight, oncall senior nurse informed, shift out to bank. Not covered but Band 5's split ward into managable areas making the ward busy but safe.

21/06/2014 Night A 1 Additional RGN booked for day shift for medical management. Short of 1 HCA at night. Shift out to NHSP & A5 completed and sent to Senior Nurse on call. Not covered but staff on duty shared responsibility through having 2 bays each and doing all their own vital signs. Busy but safe.

24/06/2014 Day A Band 7 in numbers and not supervisory. Late cannot cover from own staff and NHSP not covered.

26/06/2014 Day A x1 RN supernumery can't work unsupervised. X6 elective patients to get in and no beds empty at present. Only 2 confirmed discharges. Band 6 co-ordinated the shift and split the rest of the staff into 2 bays each with the assistance of the hca's. Band 7 on A/L

Delivery Suite

01/06/2014 Night A no HCA for triage or D/S, will deploy from other areas

02/06/2014 Day A Support shifts vacant requiring sharing between clinical areas.

02/06/2014 Night A Support shifts vacant requiring sharing between clinical areas.

05/06/2014 Day A HCA deployed from another clinical area for day shift , 1 shift remains unfilled, day and night. Staff moved between clinical areas affected to manager activity depending on clinical demands.

05/06/2014 Night A 1 shift remains unfilled night. Staff moved between clinical areas affected to manager activity depending on clinical demands.

06/06/2014 Night A short of HCA in night will have to redeploy from other areas

07/06/2014 Day A 1 midwife DNA, agency contact, 1 redeployed to another area due to activity, therefore staff for maternity triage not available, triage re-deployed to delivery suite whilst trying to arrange cover.

09/06/2014 Day A 1 support staff shift unfilled, will require sharing between clinical areas or redeployment if shift remains unfilled on NHSP.

11/06/2014 Night A No HCA on D/Suite - shift out to NHSP. Agency midwife DNA on night shift. Shift put out again but not filled. Will have to move midwife from another area if needed.

12/06/2014 Day A 1 midwife down on DS, already out to NHSP. Redeployed staff within division to cover when needed.


19/06/2014 Day A One Midwife moved from ABC to cover shortfall.

28/06/2014 Day A 1 shift unfilled, support staff utilised, and local redeployment.

30/06/2014 Day A 1 midwife cancelled 07.40 redeployment not possible due to current activity triage centralised on delivery suite ths may need to continue to mitigate for vacant shift. 1 midwife DNA shift unfilled.

ABC

01/06/2014 Day A no HCA but will redeploy from another area

02/06/2014 Night A Support shifts vacant requiring sharing between clinical areas.

03/06/2014 Day A 1 midwife early shift unfilled, supernumerary utilised to support

04/06/2014 Night A No support staff on nights. Will get HCA to help from another area if needed

05/06/2014 Day A Day and night. No HCA. Shift put out to NHSP. Midwife shift unfilled on NHSP. Support from other clinical area

05/06/2014 Night A Day and night. No HCA. Shift put out to NHSP. Midwife shift unfilled on NHSP. Support from other clinical area

07/06/2014 Day A 1 midwife deployed from delivery suite due to activity, no support staff available.

11/06/2014 Day A No Midwife on late. Shift put out to NHSP. Support from other clinical area

13/06/2014 Night A No HCA on night. Shift put out to NHSP. Will have to get help from another area if not filled.

15/06/2014 Day A One midwive down on late shift. Shift out to bank but not filled. HCA from Victoria Ward to help.

15/06/2014 Night A No HCA on night shift. Shift out to bank but not filled. HCA from Victoria Ward to help.

28/06/2014 Day A 1 shift unfilled activity managed within current staffing capacity.

Victoria

01/06/2014 Day A no HCA support will redeploy from another area if required

04/06/2014 Night A No support staff on nights. Will get HCA to help from another area if needed

10/06/2014 Night A Will have to get HCA from ABC to cover Victoria Ward as well as ABC

16/06/2014 Day A HCA had to be redeployed to another area. HCA from ABC to help.

16/06/2014 Night A HCA had to be redeployed to another area. HCA from ABC to help.

Katherine

02/06/2014 Night A No nursery nurse available, midwife will be required to under take these duties

03/06/2014 Day A 1 long day uncovered supernumary to support this morning, vacant shift on NHSP.

03/06/2014 Night A 1 shift vacant. Vacant shift on NHSP. Support provided from other clinical areas.

04/06/2014 Day A Only 3 midwives on day shift, vacancy put out to NHSP. Midwife sent from DS to help with discharges. 4th midwife obtained for late shift to bring up to full complement of staff.

05/06/2014 Day A Day - No HCA or nursery nurse. No shift put out to NHSP

06/06/2014 Night A short of HCA on shift will redeploy from other areas, have SN staff to assist, no nursery nurse available on night shift.

07/06/2014 Day A No support staff for early shift, shift remained unfilled NHSP. Staff shared Katherine and Knutsford.

09/06/2014 Day A support shift unfilled will require sharing between Katherine and Knutsford

11/06/2014 Day A Only 1 HCA . Will have to get HCA from other area to help. No breast feeding support workers.

11/06/2014 Night A Only 1 HCA . Will have to get HCA from other area to help. No breast feeding support workers. Only HCA on night shift


13/06/2014 Night A No HCA on night. Shift put out to NHSP. Will have to get help from another area if not filled.

14/06/2014 Day A 2 support staff shift unfilled, will require sharing between clinical areas or redeployment if shift remains unfilled on NHSP.

15/06/2014 Day A Midwife DNA'd for late shift. Shift on system but midwife not informed to work. Midwife came in and worked for 3 hours

15/06/2014 Night A Short of HCA's, will reploy within divsion to help support.

30/06/2014 Day A 1 midwife not yet arrived for duty, shift remained unfilled due to failure of temporary staff arriving for duty. Ward manager utilised to cover .

Knutsford

03/06/2014 Night A No support staff, staff will be shared between Katherine and Knutsford

06/06/2014 Day A HCA shift vacant on day, shared responsibility Knutsford and Katherine.one of 3 shortages of HCA's will redeploy.

06/06/2014 Night A HCA shift vacant on night, shared responsibility Knutsford and Katherine.one of 3 shortages of HCA's will redeploy.

07/06/2014 Day A support staff shared between clinical area Katherine and Knutsford

10/06/2014 Night A No HCA but no patients at start of shift. HCA from Katherine ward to help if needed


Appendix 2

Nursing and Midwifery Safe Staffing - Month 4

1. Purpose 1.1 This paper provides an update on the progress regarding the arrangements within the Trust for managing safe nursing and midwifery staffing levels within the inpatient wards.

2. Background

2.1 It is a national requirement for all hospitals to publish information about staffing levels on wards, including the percentage of shifts meeting their agreed staffing levels. This paper will be reported monthly.

2.2 The Trust submitted all unify data to NHS England as required by the 11th August 2014 this will be available to view on NHS Choices website on or around the 24th August allowing patients and the public to see how hospitals are performing. See Appendix 1 for July 2014 unify data by site and ward.

3. Analysis/Discussion 3.1 There has been discussion nationally that the breakdown of staffing data shown on NHS Choices does not distinguish between qualified and unqualified staff. This is seen as confusing for patients however as a Trust we do distinguish this in our reporting and the Board papers are then displayed for the public on our safe staffing page on the internet site. 3.2 On 1 July 2014 the National Institute for Health and Care Excellence (NICE 2014) published their guidance in relation to safer staffing and made a number of recommendations in relation to the following:

Organisational strategy

Principles for determining nurse staffing requirements

Setting the ward nursing staff establishments

Assessing if nursing staff available on the day meets the patients nursing needs

Monitoring and evaluating ward nursing staff establishments 3.3 The recommendation from NICE that wards implement systems to report and monitor nursing ‘Red Flags’ has attracted much debate in the press. The guidance points to a number of patient factors that would denote a Red Flag event as well as quantifying a Red

Flag in terms of staffing levels. The guidance recommends the following as constituting a Red Flag:

Less than 2 registered nurses present on a ward during any shift.

A shortfall of more than 8 hours or 25% (whichever is reached first) of registered nurse time available compared with the actual requirement for the shift. For example, if a shift requires 40 hours of registered nurse time, a red flag event would occur if less than 32 hours of registered nurse time is available for that shift. If a shift requires 15 hours of registered nurse time, a red flag event would occur if 11 hours or less of registered nurse time is available for that shift (which is the loss of more than 25% of the required registered nurse time.

Organisations to agree their own red flag events locally In response to the NICE Guidance, a gap analysis will be undertaken in September with senior nurses to benchmarking current practice against the recommendations. In particular we will be working with national leads to better understand the application of the Red Flag system and reconciling the percentages outlined above with the fill rates included in West Hertfordshire Hospitals Trust Safer Staffing submission. The outcome and action plan will be presented at the Trust Board in November 2014. 3.4 In July the Trust reported 1,094 unfilled hours for trained nurses and midwives and 841 hours above planned for health care assistants on day shifts. On night shifts 552 hours were unfilled for trained nurses/midwives against the planned hours required on duty, for healthcare assistant 839.5 hours were on duty above planned hours. Some clinical areas are noted to have an increase in hours above planned for health care assistants due to fluctuations in the acuity or dependency of patients on some shifts e.g 1:1 specials and escorts.

3.5 All shifts day and night are professionally judged for clinical safety and escalated in accordance with the Nursing and Midwifery safe staffing escalation policy. 3.6 It is important to note that actual staffing levels submitted via the unify return comprise all staff on duty including staff that were unplanned for trained and healthcare assistants e.g 1:1 specials, escorts. This in turn would distort the actual levels of staff required on duty to deliver safe patient care as these are essential staff and would be above the agreed planned hours. The data therefore should not be looked at in isolation but be considered in line with the shift red amber green (RAG) ratings exception report. See tables 1–3 below for the comparison data and trends overall in the trust and then by hospital. Table 1 – West Hertfordshire Hospitals overall percentage of filled against unplanned hours

Table 2 – St Albans City Hospital percentage of hours filled against unplanned


erOctober

November

December


Trained Nurses/Midwives Day 100.8% 97.9% 97.9%

Trained Nurses/Midwives Night 99.0% 99.1% 98.8%

Health CareAssistants Day 99.8% 99.0% 103.1%

Health Care Assistants Night 108.2% 100.3% 104.5%

Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e


Table 3 – Watford General Hospital percentage of hours filled against planned

Monthly comparison data and trends of the percentage of filled hours against planned by division is shown in tables 4–6 below. Table 4 - Medicine percentage of filled hours against planned


erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%A

vera

ge F

ill R

ate



erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%

100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e



erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e

Medicine



3.7 Across all ward and departments there were 2,370 day and night shifts 2,307 shifts were rated green, 63 rated amber and 0 shifts were rated red in July 2014. See appendix 2 for monthly detail by ward/department which also includes areas not in the unify data reporting. The trust overall saw a reduction in amber ratings during the month of July Shifts rated amber decreased by 1.87% from the previous month. See table 1 below for monthly trends. Table 1 - West Hertfordshire Trust overall percentage shift RAG rating.

The division of Women’s and children’s reported a decrease in amber rated shifts by 10.2% however the divisions of Medicine and Surgery reported an increase of amber rated shifts in July, 0.3% in medicine and 2.4% in Surgery. See tables 2-4 below for comparison data.


erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rgae

Fill

Rat

eSurgery


erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e

Womens & Childrens


rOctober

November

December January February March April

Green 98.0% 95.39% 97.3%

Amber 2.0% 4.57% 2.7%

Red 0.0% 0.04% 0.0%

Target RAG 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%100.0%

RA

G P

erc

enta

ge


Table 2 - Medicine monthly percentage shift RAG rating



3.8 All areas who rated amber on a day or night shift took action to mitigate any risks to maintain patient safety. Appendix 3 provides the detail for the safe staffing exception report for July 2014, by division and ward, with mitigations to maintain safe staffing on the amber rated days. 3.9 A total of 795.5 band 7 supervisory hours were lost in the month of July mitigating unfilled hours to maintain safe patient care within the adult in patient wards. This will be monitored closely over the coming months to identify trends in clinical areas that may impact on the ability of the Band 7 to carry out their supervisory role and responsibilities.


rOctober

November


Green 99.0% 98.0% 97.7%

Amber 1.0% 2.0% 2.3%

Red 0.0% 0.0% 0.0%

Target RAG 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

RA

G P

erc

enta

ge

Medicine


rOctober

November


Green 99.0% 98.6% 96.5%

Amber 1.0% 1.1% 3.5%

Red 0.0% 0.2% 0.0%

Target RAG 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

RA

G P

erc

enta

ge

Surgery


rOctober

November

December


Green 95.0% 87.0% 97.2%

Amber 5.0% 13.0% 2.8%

Red 0.0% 0.0% 0.0%

Target RAG 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

RA

G P

erc

enta

ge


4. Risks 4.1 There will be times when patients are admitted with higher acuity that require a higher level of staff than the agreed requirement, ie 1:1 nursing. 4.2 Data is currently sourced from both electronic and manual data entry to enable ratification of robust data collection. User error and administrative failure pose a risk to data quality.


Note the information and assurance

Note the ongoing work and actions

Tracey Carter Chief Nurse 15th August 2014

Appendix A West Hertfordshire Hospitals Unify Fill rate indicator return Staffing: Nursing, midwifery and care staff July 2014

Day Night


Care Staff



Site Code

Site Name













RWG03

St Albans City Hospital 1906 2056 892.5 1075.5 1207.5 1207.5 356.5 345

107.9% 120.5% 100.0% 96.8%

RWG02

Watford General Hospital 50621 49377 25894 26552 44263.5 43711.5 18285 19136

97.5% 102.5% 98.8% 104.7%

West Hertfordshire Hospitals Unify Fill rate indicator return by ward July 2014

Day Night Day Night


Ward name

Main 2 Specialties on each wardRegistered

midwives/nursesCare Staff

Registered

midwives/nursesCare Staff

Average fill

rate -

registered

nurses/mid

wives (%)

Average fill

rate - care

staff (%)

Average fill

rate -

registered

nurses/mid

wives (%)

Average fill

rate - care

staff (%)

Site code *The

Site code is

automatically

populated when

a Site name is

selected

Hospital Site name Specialty 1 Specialty 2

Total

monthly

planned

staff hours

Total

monthly

actual staff

hours

Total

monthly

planned

staff hours

Total

monthly

actual staff

hours

Total

monthly

planned

staff hours

Total

monthly

actual staff

hours

Total

monthly

planned

staff hours

Total

monthly

actual staff

hours

RWG02Watford General Hospital -

RWG02AAU Blue Level 1

300 - GENERAL

MEDICINE1174.5 1120.5 713 747.5 1069.5 1058 713 736 95.4% 104.8% 98.9% 103.2%


RWG02AAU Yellow Level 1

300 - GENERAL

MEDICINE1197 1177.5 713 713 1069.5 1058 713 736 98.4% 100.0% 98.9% 103.2%


RWG02AAU Green Level 1

300 - GENERAL

MEDICINE1219.5 1204 713 839.5 1069.5 1069.5 713 793.5 98.7% 117.7% 100.0% 111.3%


RWG02AAU Red Suite

300 - GENERAL

MEDICINE1219.5 1215.5 713 736 1069.5 1069.5 356.5 379.5 99.7% 103.2% 100.0% 106.5%


RWG02AAU Blue Level 3

300 - GENERAL

MEDICINE1456 1417.5 1069.5 1046.5 1426 1403 713 701.5 97.4% 97.8% 98.4% 98.4%


RWG02AAU Yellow Level 3

300 - GENERAL

MEDICINE1219.5 1211.5 713 747.5 1069.5 1035 356.5 460 99.3% 104.8% 96.8% 129.0%


RWG02

AAU Green & Purple

Level 3

300 - GENERAL

MEDICINE1833 1810 1426 1460.5 1426 1391.5 713 770.5 98.7% 102.4% 97.6% 108.1%


RWG02Bluebell

430 - GERIATRIC

MEDICINE1583.5 1587 1426 1437.5 1426 1437.5 1426 1460.5 100.2% 100.8% 100.8% 102.4%


RWG02Winyard

430 - GERIATRIC

MEDICINE1197 1185.5 713 674.5 1069.5 1035 713 759 99.0% 94.6% 96.8% 106.5%


RWG02Sarratt

430 - GERIATRIC

MEDICINE1917.5 2008 1658.5 2150 1782.5 1679 1069.5 1736.5 104.7% 129.6% 94.2% 162.4%


RWG02Croxley

430 - GERIATRIC

MEDICINE1583.5 1636 1302 1467.5 1426 1426 1069.5 1173 103.3% 112.7% 100.0% 109.7%


RWG02

Coronary Care Unit

(CCU)320 - CARDIOLOGY 1531 1519.5 264.5 241.5 1426 1403 0 23 99.2% 91.3% 98.4% #DIV/0!


RWG02Cassio

300 - GENERAL

MEDICINE1234.5 1207.5 713 977.5 1069.5 1058 356.5 632.5 97.8% 137.1% 98.9% 177.4%


RWG02Gade

370 - MEDICAL

ONCOLOGY1212 1231 713 874 1069.5 1058 356.5 483 101.6% 122.6% 98.9% 135.5%


RWG02Heronsgate

300 - GENERAL

MEDICINE1204.5 1196 828 851 1069.5 1069.5 356.5 460 99.3% 102.8% 100.0% 129.0%


RWG02Aldenham

300 - GENERAL

MEDICINE2093.5 2047.5 1265 1368 1955 1943.5 540.5 621 97.8% 108.1% 99.4% 114.9%


RWG02

Acute Stroke Unit

Watford

300 - GENERAL

MEDICINE2630.5 2580.5 1302 1352 2495.5 2484 1069.5 1081 98.1% 103.8% 99.5% 101.1%

RWG03St Albans City Hospital -

RWG03De La Mare/Beckett

100 - GENERAL

SURGERY1906 2056 892.5 1075.5 1207.5 1207.5 356.5 345 107.9% 120.5% 100.0% 96.8%


RWG02Letchmore

100 - GENERAL

SURGERY1182 1154 713 690 1069.5 1069.5 356.5 356.5 97.6% 96.8% 100.0% 100.0%


RWG02Ridge

100 - GENERAL

SURGERY1568.5 1583.5 1069.5 989 1069.5 1000.5 713 713 101.0% 92.5% 93.5% 100.0%


RWG02Flaunden

100 - GENERAL

SURGERY1591 1587 1069.5 1069.5 1426 1288 356.5 425.5 99.7% 100.0% 90.3% 119.4%


RWG02Cleves

100 - GENERAL

SURGERY1227 1245.5 1069.5 1044 1069.5 1058 356.5 529 101.5% 97.6% 98.9% 148.4%


RWG02Langley

100 - GENERAL

SURGERY1135 1058.5 448.5 536.5 713 678.5 356.5 345 93.3% 119.6% 95.2% 96.8%


RWG02Combined ITU

192 - CRITICAL

CARE MEDICINE5428 5251.5 356.5 318 5186.5 5198 333.5 299 96.7% 89.2% 100.2% 89.7%


RWG02Starfish

321 - PAEDIATRIC

CARDIOLOGY1334 1312.5 356.5 371.5 1069.5 977.5 356.5 310.5 98.4% 104.2% 91.4% 87.1%


RWG02SCBU

321 - PAEDIATRIC

CARDIOLOGY2219.5 2323 1000.5 724 2185 2369 1012 540.5 104.7% 72.4% 108.4% 53.4%


RWG02Elizabeth Ward

502 -

GYNAECOLOGY1553.5 1582 713 677 1069.5 1069.5 713 609.5 101.8% 95.0% 100.0% 85.5%


RWG02Delivery Suite 501 - OBSTETRICS 3613.5 3278.5 713 590.5 3208.5 3151 713 517.5 90.7% 82.8% 98.2% 72.6%


RWG02ABC 501 - OBSTETRICS 1302 1105 356.5 336.5 1069.5 1058 356.5 287.5 84.9% 94.4% 98.9% 80.6%


RWG02Victoria 501 - OBSTETRICS 945.5 704.5 356.5 370.5 713 713 356.5 322 74.5% 103.9% 100.0% 90.3%

Watford General Hospital -

Appendix B Number of day and night shifts (includes long days early and late shifts) planned against actual on duty July 2014. Please note the actual staff on duty would include staff unplanned but essential to maintain patient safety e.g. 1:1 specials and staff rostered and working clinically on a period of supervision (orientation). These staff would be in addition to the planned staffing levels and distort the actual required staffing levels

Division Area

No. of Day Shifts

No. of Night Shifts

No. of Day Shifts

No. of Night Shifts



Medicine

AAU Blue Level 1 107 103 93 92 62 65 62 64

AAU Yellow Level 1 110 109 93 92 62 62 62 64

AAU Green Level 1 113 112 93 93 62 73 62 69

AAU Red Suite 113 113 93 93 62 64 31 33

AAU Triage 187 163 93 92 92 100 62 59

AAU Blue Level 3 128 125 124 122 93 91 62 61

AAU Yellow Level 3 113 113 93 90 62 65 31 40


Bluebell 145 146 124 125 124 125 124 127

Winyard 110 109 93 90 62 59 62 66

A&E 310 305 310 318 124 119 62 60

UCC Hemel 93 93 62 62 31 31 0 0

MIU SACH 62 62 0 0 0 0 0 0

Sarratt 173 184 155 146 155 188 93 151

Croxley 145 152 124 124 124 137 93 102

CCU 138 137 124 122 23 21 0 2

Cassio 115 113 93 92 62 85 31 55

Gade 112 114 93 92 62 76 31 42

Heronsgate 111 112 93 93 72 74 31 40

Aldenham 189 185 170 169 110 120 47 54


Total 2975 2945 2464 2444 1661 1810 1101 1250

Surgery

Beckett 30 36 12 12 13 17 0 0

De La Mare 139 156 93 93 62 88 31 30

Letchmore 108 108 93 93 62 60 31 31

Flaunden 146 146 124 112 93 93 31 37

Ridge 143 145 93 87 93 86 62 62

Cleves 114 117 93 92 93 96 31 46

Langley 106 99 62 59 39 47 31 30

Combined ITU 472 457 451 452 31 28 29 26

Total 1258 1264 1021 1000 486 515 246 262

Wo

me

n's

& C

hild

ren

s

Paediatrics

Starfish 116 119 93 85 31 33 31 27

CED 124 129 93 90 0 1 0 1

Safari Day Unit 62 67 0 0 23 18 0 0

Neonatal Unit 190 177 189 186 29 26 27 8



Maternity

Delivery Suite 333 318 279 274 62 69 62 45

Alexandra BC 124 120 93 92 31 35 31 25

Victoria 93 76 62 62 31 38 31 28

Katherine 155 153 93 91 93 81 62 51

Knutsford 31 30 31 31 31 31 31 25

Total 1372 1357 1027 1019 451 433 398 303

Appendix C July 2014 Trust safe staffing exception report








Comments, Mitigation - Actions taken to Ensure safe Staffing Levels

Me

dic

ine

AAU Blue L1

19/07/2014 Day A Band 7 to provide support to the staff

AAU Green L1

05/07/2014 Day A Down an RN in the day shift out to nhsp/agency not covered. Triage will help to support

17/07/2014 Day A Band 7 in the numbers till 3pm. 1x Pts on bipap. 18 iv medication and one nurse does IV's

AAU Triage

19/07/2014 Day A Band 7 to support in Triage

21/07/2014 Night A 1 HCA down at night. Support from Green L1

22/07/2014 Day A 2 nurses short for the long day, senior sister will be working in the number on long day. Extra hca

AAU Yellow L1

28/07/2014 Day A Band 7 to support.

29/07/2014 Day A 1 RN down for the day shift. Band 6 in the numbers

Bluebell 14/07/2014 Day A Band 7 working in the numbers, Winyard ward to support as required

Winyard 22/07/2014 Day A x1 RN out to agency. Band 7 on late shift. Bluebell ward to support

A&E

18/07/2014 Day A PDN to support clinically no band 7. Medical staff to cover ANP workload. Trying to rearrange night ANP to come in early

22/07/2014 Day A enp needed to be sent to UCC to ensure UCC was safe.

31/07/2014 Day A staff moved to ensure all areas covered Clinical facilitator worked in the department. Agency nurses arrived very late.

Acute Stroke Unit

11/07/2014 Day A

3 trained sick but 1 is covered by agency. 1 overseas nurse without PIN working as HCA. Currently 7 empty beds which helps with safety but will become more difficult if we start admitting. 1 HCA sent to support ward. No further trained staff available. maintained 8 empty beds throughout day but acuity reflects amber rating

Aldenham 19/07/2014 Day A nurse awaiting pin number - supernumerary working in the numbers

Cassio 06/07/2014 Day A 1RN DNA on a LD; 1 CSW worked from another ward from 0945. 1 Special CSW LD and N

13/07/2014 Day A

X 1 special Agency R/N DNA. NHSP informed, on duty were 2 sisters from the ward 2 CSW from the ward and senior nurse on call sent a Csw to ward

CCU

06/07/2014 Night A senior sister can be contacted for support, shift out to NHSP, Bed manager informed x1 RN short.

21/07/2014 Night A unconfirmed booking for agency HCA (LD). Band 5 swapped with HCA as Gade ward short. Band 7 can be contacted for support

29/07/2014 Day A 1 staff nurse short, out to NHSP. Matron informed. Band 7 can be contacted for support.

Croxley 19/07/2014 Day A x2 specials booked but did not turn up for duty. Support from Sarratt ward

Gade

10/07/2014 Day A one HCA short on the LD and require special for LD CSW this was escalated to senior nurse no help available

12/07/2014 Night A 1 HCA special for patient. 1 RN SHIFT OUT STANDING escalated to senior nurse no other staff member available to help.

21/07/2014 Day A Ward will be one RN down on the late shift due to cancellation by bank. Supervisory in the numbers

22/07/2014 Day A 1 RN short was required for escort. No help available used ward staff, this left the ward short. This was escalated to senior nurse, no help available

Heronsgate

04/07/2014 Day A

Have 2 patients that require 1:1, one patient has special book which has not been covered on NHSP, 2nd patient has become confused over night, after speaking with staff have requested special as they have needed staff memeber with her at all times. escalated to Matron, senior sister stepped into bay.

05/07/2014 Day A Extra HCA for special for confused staff. Agency nurse DNA shift, supervisory stepped into bay, escalated to matron

27/07/2014 Day A unfilled shift on long day it is out to agency, awaiting to see if it fills. Tried to move staff to cover unable to. Escalated to bed manager and on call sister.

Sarratt 19/07/2014 Day A RN cancelled long day. 3rd year student supported vacant shift

Surg

ery

ITU

15/07/2014 Day A Outreach nurse was required to work in ITU during day shift to support the unit.

19/07/2014 Night A x1 agency nurse cancelled late. Outreach nurse pulled out to work on unit. X1 agency ward trained nurse booked in to help.

21/07/2014 Night A Admitted ward patients as hospital full, unable to admit electives , outreach service suspended to take patients. Escalated to Matron +Site manager unit safe.. Night Comment: Outreach service should be re-established overnight. No capacity for level 3 admission. No level 1 patients on ITU.

26/07/2014 Night A Unit full with 19 patients no ward patients. Escalated to Matron . Staffing safe.

De La Mare 22/07/2014 Day A 1 RN sick on a long day, covered the late shift and Beckett closing this pm and staff will come up to De la Mare

Flaunden 28/07/2014 Night A 4th trained cancelled late pm with nhsp and not replaced. Took tap from ridge ward = 3 + 2

30/07/2014 Night A one RGN has cancelled at 03.30. was escalated on a5 authorised shift out to nhsp not covered. B2 spare overnight covered it via bed manager authorisation.

Letchmore

01/07/2014 Night A liaise with matron as senior nurse for night shift has commenced paternity leave which leaves only junior staff on the ward

05/07/2014 Day A One R.N short. Poor skill mix on ward and in ESAL, Bed manager made aware . Band 4 Tap Nurse on duty today. Additional R.N for late shift.

14/07/2014 Day A RN sick LD, escalated to matron, band 7 counted in numbers for early, HCA relocated from another ward, RN shift requested from NHSP

19/07/2014 Day A One HCA on Sick leave. Bleep holder and bed manager made aware at 20:00 on 18/7/14. Shift placed on NHS Professionals not currently filled. Shift time changed to 10:00, Shift to be "unlocked" for agency this morning. Will share 10:00 to 22:00 nurse with ESAU.

21/07/2014 Day A band 6 sick LD, band 7 counted in numbers early shift, will escalate to matron

25/07/2014 Day A 1 RN sick LD, band 7 incuded in numbers AM, will escalate to matron

30/07/2014 Day A 1 RN sick for LD, band 7 counted in numbers. 2nd RN in ESAU to work between ward and ESAU. 1 CSW is an assisted practitioner who can take a bay

Ridge 19/07/2014 Night A 1 hca short,senior nurse on call informed. Healthcare from Langley ward assisted when needed

20/07/2014 Night A 1 R/N short.Senior nurse on call informed. ,unable to get trained,extra hca sent by bleepholder during the night

Wo

me

ns

& C

hild

ren

s

Pae

dia

tric

s

CED

02/07/2014 Day A Risk mitigated by Senior sister and moving staff around the service.

14/07/2014 Night A Night out to agencies. Not filled but staff on ward and A&E aware and covered as required.

15/07/2014 Night A MLD out to agencies. A&E and Starfish aware and can help as required

18/07/2014 Night A Starfish and A&E aware, will support if needed. Senior Sister on call aware. Agency not filled.

20/07/2014 Day A MLD one staff nurse short due to sickness. A&E and Ward aware that help may be required.

22/07/2014 Night A out to agency. Agency filled

27/07/2014 Night A x1 member of nursing team on N is newly qualified, awaiting PIN. A&E and Starfish aware, will support if needed

Safari 23/07/2014 Day A Senior Sister assisting on ward

Starfish

09/07/2014 Night A Ced aware and able to assist through the night if needed .Senior nurse on-call available via telephone.

10/07/2014 Night A Night shift down to last minute sickness. Senior nurse on call aware and available by phone for advice.Ced available toprovide help if needed.

11/07/2014 Day A Staff sickness at short notice, x2 band 7's working on the ward to assist, CED and safari unit able to provide assistance where needed.

Gyn

aeco

logy

Elizabeth

09/07/2014 Day A x1 HCA doing the housekeepers job. X6 electives to come in, only 1 bed at present. X1 medical management of miscarriage to bring in and the nurse special not filled for that.

14/07/2014 Day A Band 5 not covered and Band 2 DNA.Band 2 early for housekeper. Staff split to 2 bays each and all discharges/admissions to be completed by 2pm to mitigate risk from returning afternoon list

17/07/2014 Day A x1 RN shift outstanding. X2 medical managements of miscarriages coming in today and they are usually specialled and they will heighten the activity on the ward. Band 7 to assist on the ward

19/07/2014 Day A x1 RN phoned in sick in the night. X 1 HCA went off sick late last night. Supernumerary trained nurse awaiting pin supporting clinically, HCA cover for 7.5 hours of 11.5 hour shift

22/07/2014 Day A x1 HCA short. X 8 elective patients to bring in. Band 7 in the numbers

30/07/2014 Day A Only 3 nurses on the ward after 5pm. 6 electives to come in. 6 medical patients. 2 surgical patients. 4 breast patients. Supervisory in the numbers

Mat

er

nit

y Delivery Suite

07/07/2014 Night A one RM short on shift , high levels of activity, sit rep changed at 22:00, called in community as 9 x labouring Patients , 1HDU and high risk an patient requiring 1:1,informed matron and community midwifery manager, 10 deliveries between 22:00 and 04:00 including admission of a high risk CSF case, with violent family connections and high flight risk. Safe staffing status now amber .

of 52

Appendix 3

Nursing and Midwifery Safe Staffing - Month 5

1. Purpose 1.1 This paper provides an update on the progress regarding the arrangements for managing safe nursing and midwifery staffing levels within the inpatient wards during August 2014.

2. Background 2.1 The Trust submitted all unify data to NHS England as required by the 9th September 2014 which is available to view on NHS Choices website at the end of the month. See Appendix A for August 2014 unify data by site and ward.

3. Analysis/Discussion 3.1 The Trust reported 1,633 unfilled hours for trained nurses and midwives and 1,124 hours unfilled against planned for health care assistants on day shifts. On night shifts 402 hours were unfilled for trained nurses/midwives against the planned hours required on duty, and for healthcare assistant 104 hours were on duty above planned hours. 3.2 Comparison data and trends overall in the Trust can be seen in tables 1-3 below. This comprises of all staff on duty including unplanned essential staff e.g. 1:1 specials. The overall fill rate shows a reduction from the previous month. Table 1 – West Hertfordshire Hospitals - overall percentage of hours filled against planned


erOctober

November

December


Trained Nurses/Midwives Day 100.8% 97.9% 97.9% 96.9%

Trained Nurses/Midwives Night 99.0% 99.1% 98.8% 99.1%

Health CareAssistants Day 99.8% 99.0% 103.1% 95.7%

Health Care Assistants Night 108.2% 100.3% 104.5% 100.6%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e


of 52

Table 2 – St Albans City Hospital - percentages of hours filled against planned

Table 3 – Watford General Hospital - percentages of hours filled against planned

Monthly comparison data and trends of the percentage of filled hours against planned by division is shown in tables 4–6 below. Table 4 - Medicine percentage of filled hours against planned


erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e



erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e



erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e

Medicine

of 52



3.3 Some clinical areas are noted to have an increase in hours above planned for health care assistants due to fluctuations in the acuity or dependency of patients on some shifts e.g. 1:1 specials and escorts. 3.4 Across all wards and departments there were 2,363 day and night shifts of these 2,261 shifts were rated green, 102 rated amber and 0 shifts were rated red. See appendix B for monthly detail by ward/department which also includes areas not in the unify data reporting. 3.5 There was a 1.6% increase in amber ratings during the month of August. See table 1 below for monthly trends. Table 1 - West Hertfordshire Trust overall percentage shift RAG rating.


erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rgae

Fill

Rat

e

Surgery


erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e

Womens & Childrens


erOctober

November

December






Target Fill Rate 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

60.0%70.0%80.0%90.0%100.0%110.0%120.0%130.0%140.0%

Ave

rage

Fill

Rat

e


of 52

3.6 The division of Medicine reported an increase in amber rated shifts of 1.6%, Surgery a decrease of 0.6% and Women’s and children’s an increase of 1.7% in August from the previous month. See tables 2-4 below for comparison data. Table 2 - Medicine monthly percentage shift RAG rating



3.7 All areas who rated amber on a day or night shift took action to mitigate any risks to maintain patient safety. Appendix C provides the detail for the safe staffing exception report for August 2014, by division and ward, with mitigations to maintain safe staffing on the amber rated days.


erOctober

November

December


Green 99.0% 98.0% 97.7% 95.3%

Amber 1.0% 2.0% 2.3% 4.7%

Red 0.0% 0.0% 0.0% 0.0%

Target RAG 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

RA

G P

erce

nta

ge

Medicine


erOctober

November

December


Green 99.0% 98.6% 96.5% 97.1%

Amber 1.0% 1.4% 3.5% 2.9%

Red 0.0% 0.0% 0.0% 0.0%

Target RAG 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

RA

G P

erc

enta

ge

Surgery


rOctober

November

December


Green 95.0% 87.0% 97.2% 95.5%

Amber 5.0% 13.0% 2.8% 4.5%

Red 0.0% 0.0% 0.0% 0.0%

Target RAG 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

RA

G P

erc

enta

ge


of 52

3.8 A total of 862.5 band 7 supervisory hours were lost in the month of August mitigating unfilled hours to maintain safe patient care within the adult in patient wards. This was an increase of 67 hours on the previous months.

4. Risks 4.1 There will be times when patients are admitted with higher acuity that require a higher level of staff than the agreed requirement, i.e. 1:1 nursing. 4.2 Data is currently sourced from both electronic and manual data entry to enable ratification of robust data collection. User error and administrative failure pose a risk to data quality.


Note the information and assurance Tracey Carter Chief Nurse and DIPC 15th September 2014

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Appendix A West Hertfordshire Hospitals Unify Fill rate indicator return Staffing: Nursing, midwifery and care staff August 2014

Day Night


Care Staff



Site Code Site Name













RWG03 St Albans City Hospital 1811 1782 862.5 998 1184.5 1173 345 345

98.4% 115.7% 99.0% 100.0%

RWG02 Watford General Hospital 50078 48474 25951.5 24666.5 44631.5 44240.5 18147 18250.5

96.8% 95.0% 99.1% 100.6%

of 52

West Hertfordshire Hospitals Unify Fill rate indicator return by ward August 2014

Day Night Day Night


Ward name

Main 2 Specialties on each ward Registered midwives/nurses Care Staff Registered midwives/nurses Care Staff





Site code Hospital Site name Specialty 1 Specialty 2 Total monthly planned staff hours










1148.5 1064 713 724.5 1069.5 1058 713 690 92.6% 101.6% 98.9% 96.8%


AAU Yellow Level 1 300 - GENERAL MEDICINE

1122 12060.5 713 713 1069.5 1069.5 713 736 94.5% 100.0% 100.0% 103.2%


AAU Green Level 1 300 - GENERAL MEDICINE

1167 1097 713 724 1069.5 989 713 690 94.0% 101.5% 92.5% 96.8%

RWG02

Watford General Hospital - RWG02

AAU Red Suite 300 - GENERAL MEDICINE

1219.5 1208 713 713 1069.5 1081 356.5 460 99.1% 100.0% 101.1% 129.0%



1441 1360.5 1069.5 1035 1426 1380 713 713 94.4% 96.8% 96.8% 100.0%


AAU Yellow Level 3 300 - GENERAL MEDICINE

1204.5 1166 713 690 1069.5 1058 356.5 356.5 96.8% 96.8% 98.9% 100.0%


AAU Green & Purple Level 3 300 - GENERAL MEDICINE

1787.5 1718.5 1426 1368.5 1426 1403 713 713 96.1% 96.0% 98.4% 100.0%


Bluebell 430 - GERIATRIC MEDICINE

1568.5 1522.5 1426 1380 1426 1414.5 1426 1460.5 97.1% 96.8% 99.2% 102.4%


Winyard 430 - GERIATRIC MEDICINE

1183 1075.5 713 713 1069.5 1023.5 713 724.5 90.9% 100.0% 95.7% 101.6%


Sarratt 430 - GERIATRIC MEDICINE

1932.5 2063.5 1658.5 1376 1782.5 1771 1069.5 1115.5 106.8% 83.0% 99.4% 104.3%


Croxley 430 - GERIATRIC MEDICINE

1568.5 1579 1302 1207.5 1426 1391.5 1069.5 966 100.7% 92.7% 97.6% 90.3%

RWG02 Watford General Hospital - RWG02 Coronary Care Unit (CCU) 320 - CARDIOLOGY 1546 1488.5 241.5 264.5 1426 1380 0 23 96.3% 109.5% 96.8% #DIV/0!


Cassio 300 - GENERAL MEDICINE

1189.5 1178 713 816.5 1069.5 1058 356.5 460 99.0% 114.5% 98.9% 129.0%


Gade 370 - MEDICAL ONCOLOGY

1189.5 1170 713 713 1069.5 1023.5 356.5 356.5 98.4% 100.0% 95.7% 100.0%


Heronsgate 300 - GENERAL MEDICINE

1212 1223.5 805 805 1069.5 1058 356.5 345 100.9% 100.0% 98.9% 96.8%


Aldenham 300 - GENERAL MEDICINE

2059.5 1971 1276.5 1345.5 2139 2012.5 356.5 552 95.7% 105.4% 94.1% 154.8%


Acute Stroke Unit Watford 300 - GENERAL MEDICINE

2600.5 2504.5 1302 1252.5 2495.5 2426.5 1069.5 1046.5 96.3% 96.2% 97.2% 97.8%

RWG03 St Albans City Hospital - RWG03

De La Mare/Beckett 100 - GENERAL SURGERY

1811 1782 862.5 998 1184.5 1173 345 345 98.4% 115.7% 99.0% 100.0%


Letchmore 100 - GENERAL SURGERY

1174.5 1205 713 698 1069.5 1058 356.5 391 102.6% 97.8% 98.9% 109.7%


Ridge 100 - GENERAL SURGERY

1553.5 1507 1069.5 931.5 1069.5 1058 713 713 97.0% 87.1% 98.9% 100.0%


Flaunden 100 - GENERAL SURGERY

1561 1518.5 1069.5 1100 1426 1403 356.5 414 97.3% 102.9% 98.4% 116.1%


Cleves 100 - GENERAL SURGERY

1189.5 1189 1069.5 997.5 1069.5 1046.5 356.5 736 100.0% 93.3% 97.8% 206.5%


Langley 100 - GENERAL SURGERY

1082 1051 471.5 471.5 713 701.5 356.5 333.5 97.1% 100.0% 98.4% 93.5%


Combined ITU 192 - CRITICAL CARE MEDICINE

5566 5481.5 356.5 345 5416.5 5382 322 322 98.5% 96.8% 99.4% 100.0%


Starfish 321 - PAEDIATRIC CARDIOLOGY

1311 1180 356.5 345 1069.5 1069.5 356.5 333.5 90.0% 96.8% 100.0% 93.5%


SCBU 321 - PAEDIATRIC CARDIOLOGY

2139 2426.5 1069.5 713 2139 2541.5 1069.5 563.5 113.4% 66.7% 118.8% 52.7%

RWG02 Watford General Hospital - RWG02 Elizabeth Ward 502 - GYNAECOLOGY 1508.5 1521.5 713 731.5 1069.5 1058 713 701.5 100.9% 102.6% 98.9% 98.4%

RWG02 Watford General Hospital - RWG02 Delivery Suite 501 - OBSTETRICS 3591 3325.5 713 646.5 3208.5 3151 713 655.5 92.6% 90.7% 98.2% 91.9%

RWG02 Watford General Hospital - RWG02 ABC 501 - OBSTETRICS 1302 1070 356.5 357.5 1069.5 1046.5 356.5 287.5 82.2% 100.3% 97.8% 80.6%

RWG02 Watford General Hospital - RWG02 Victoria 501 - OBSTETRICS 945.5 719.5 356.5 310.5 713 690 356.5 333.5 76.1% 87.1% 96.8% 93.5%

RWG02 Watford General Hospital - RWG02 Katherine 501 - OBSTETRICS 1658.5 1476.5 1069.5 844.5 1069.5 1081 713 701.5 89.0% 79.0% 101.1% 98.4%


Knutsford 501 - OBSTETRICS 356.5 352.5 356.5 333.5 356.5 356.5 356.5 356.5 98.9% 93.5% 100.0% 100.0%

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Appendix B - Number of day and night shifts (includes long days early and late shifts) planned against actual on duty August 2014. Please note the actual staff on duty would include staff unplanned but essential to maintain patient safety e.g. 1:1 specials and staff rostered and working clinically on a period of supervision (orientation). These staff would be in addition to the planned staffing levels and distort the actual required staffing levels

Division Area

No. of Day Shifts

No. of Night Shifts

No. of Day Shifts

No. of Night Shifts



Medicine Overall 2919 2844 2480 2433 1659 1618 1085 1110

Surgery Overall 1246 1245 1047 1036 488 503 245 283

Womens & Childrens Overall 1332 1286 1023 1052 435 395 403 342

Trust Overall 5497 5375 4550 4521 2582 2516 1733 1735

Division Area

No. of Day Shifts

No. of Night Shifts

No. of Day Shifts

No. of Night Shifts



Medicine

AAU Blue Level 1 102 96 93 92 62 63 62 60

AAU Yellow Level 1 100 95 93 93 62 62 62 64

AAU Green Level 1 106 103 93 87 62 64 62 60

AAU Red Suite 113 112 93 94 62 62 31 40

AAU Triage 186 160 93 92 93 79 62 60

AAU Blue Level 3 126 119 124 120 93 90 62 62

AAU Yellow Level 3 111 108 93 92 62 60 31 31


Bluebell 143 139 124 124 124 120 124 127

Winyard 102 97 93 89 62 63 62 62

A&E 310 298 310 311 124 113 62 58

UCC Hemel 93 92 62 62 31 31 0 0

MIU SACH 62 61 0 0 0 0 0 0

Sarratt 175 193 155 154 155 120 93 97

Croxley 143 146 124 121 124 113 93 84

CCU 140 135 124 120 21 23 0 2

Cassio 109 108 93 92 62 71 31 40

Gade 109 109 93 89 62 62 31 31

Heronsgate 112 113 93 92 70 70 31 30

Aldenham 185 178 186 175 111 114 31 48


Total 2919 2844 2480 2433 1659 1618 1085 1110

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Division Area

No. of Day Shifts

No. of Night Shifts

No. of Day Shifts

No. of Night Shifts



Surgery

Beckett 25 25 10 10 13 16 0 0

De La Mare 138 147 93 92 62 85 31 30

Letchmore 107 111 93 92 62 61 31 34

Flaunden 142 139 124 122 93 96 31 36

Ridge 141 138 93 92 93 81 62 62

Cleves 109 110 93 91 93 93 31 64

Langley 100 98 62 61 41 41 31 29

Combined ITU 484 477 479 476 31 30 28 28

Total 1246 1245 1047 1036 488 503 245 283

Division Area

No. of Day Shifts

No. of Night Shifts

No. of Day Shifts

No. of Night Shifts



Wo

men

's &

Ch

ild

ren

s

Paediatrics

Starfish 114 104 93 93 31 30 31 29

CED 124 130 93 94.5 0 0 0 0

Safari Day Unit 40 52 0 0 1 7 0 0

Neonatal Unit 186 199 186 207 31 18 31 6



Maternity

Delivery Suite 330 305 279 274 62 59 62 57

Alexandra BC 124 105 93 91 31 37 31 25

Victoria 93 68 62 60 31 27 31 29

Katherine 155 139 93 94 93 79 62 61

Knutsford 31 31 31 31 31 29 31 31

Total 1332 1286 1023 1052 435 395 403 342

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Appendix C

July 2014 Trust safe staffing exception report








Comments, Mitigation - Actions taken to Ensure safe Staffing Levels

Me

dic

ine

A&E

18/08/2014 Day A Supported by A&E lead nurse and ANP

22/08/2014 Day A Supported by A&E lead nurse and ANP

25/08/2014 Night A moved staff within the department to mitigate

31/08/2014 Day A staff moved around to make areas safe used HCA as 4

th member of staff in resus

AAU Blue L1 28/08/2014 Day A Band 7 supported the bay

AAU Blue L3 10/08/2014 Night A One SN still not filled in by NHSP. Support from G&P L3

AAU Green L1

30/08/2014 Day A RN Shift out to NHSP but not filled. Band 7 in aau will support the area.

31/08/2014 Night A 2 RN down tonight in green out to NHSP. Will look at staff with in aau level 1 and make it safe. 1 shift filled

AAU Red Suite

01/08/2014 Day A Requiring 1:1 special for a mental health patient - escalated A/W approval from senior nursing.

01/08/2014 Night A Requiring 1:1 special for a mental health patient - escalated A/W approval from senior nursing.

02/08/2014 Day A RN down due to SSS. Escalted to senior nurse. RN sent to cover.

16/08/2014 Day A 1 x registered nurse off sick, shift put out to bank yesterday but has not filled. Band 7 on AAU made aware to support.

24/08/2014 Day A 1 RN outstanding for night shift. Escalated to on call senior nurse. Datix form recorded.

25/08/2014 Night A 1 rn down as agency nurse did not attend. Bed manager and senior nurse aware.

29/08/2014 Day A 1 HCA off sick. Matron aware. Unable to get cover. Ward was safe.

AAU Triage

AAU Triage

03/08/2014 Night A Supported from Green L1

04/08/2014 Day A SSR will be working in the number this morning

20/08/2014 Day A 1 RN +HCA needed to special patient in SR13. Band 7 supervisory supporting clinically

30/08/2014 Day A RN not filled, out to NHSP band 7 to support the area.

Bluebell

02/08/2014 Day A LD for RN out on NHSP, but not yet covered. Escalated to senior nurse.

05/08/2014 Day A band 7 to help on the ward

09/08/2014 Day A Down RN sick. Escalated to senior nurse

13/08/2014 Night A Long day agency RN, name on system but has not attended. HCA has rang in sick early hours. Will call NHSP to follow up RN. RN redepoyed to area to work the LD.

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Winyard

06/08/2014 Night A x1 band 5 nurse not filled out to agency matron aware.

09/08/2014 Day A 2 trained and 1 supernumeray. Will escalate to the matron.

10/08/2014 Day A Phoned staffs but no one available to work. Informed bed manager today re: staffing number.

11/08/2014 Day A x1 band 5 off sick. Will d/w my matron.

23/08/2014 Day A x1 band 5 down and special not filled for an aggressive patient. Senior nurse on call authorised A5 but not filled. Band 5 out to agency. Regular staff unable to work.

30/08/2014 Day A x1 band 5 down for LD but an extra HCA.

30/08/2014 Night A X1 band 5 down for night. Senior nurse on call aware and shifts out to agency.

Acute Stroke Unit

07/08/2014 Day A 1 trained and 1 hca sick. No cover from other areas available. Escalated to matron

11/08/2014 Day A Need RN and HCA for the Stroke gym for LD and Night. RN and HCA moved from AAU surge to support surge into gym. Acuity of patients remains high

23/08/2014 Day A Escalated to senior nurse on call

Aldenham

23/08/2014 Day A Trained nurse awaiting pin number and HCA called in sick 22/08/14 at 21:00. Tried to swap HCA with RN with another ward. Escalated to Senior nurse on call.

27/08/2014 Day A HDU patients x 3. Escalated to matron who will support clinically where required.

30/08/2014 Day A RGN awaiting pin, HCA not booked came for shift . Three patients needing special in HDU. Supported from CCU

Cassio

17/08/2014 Night A Bed manager was made aware as R/N from Agency did not turn up ward ran on 2 R/N and 2 CSW as bed manager found a spare CSW.

23/08/2014 Day A Ward R/N went home sick Bed manager and NHSP aware that shift was required not covered ward ran below staffing 2 R/N 2 CSW

24/08/2014 Day A Bed manager aware NHSP unable to fill ward ran on 2 R/N 2 CSW below staffing levels. We were down R/N due to sickness

CCU

01/08/2014 Night A 1 trained short on day shift and 1 trained short on night shft, out in the bank but still not filled in. Band 7 in numbers on Early

03/08/2014 Night A Band 7 available for support

09/08/2014 Day A LD-HCA cover instead of registered nurse

09/08/2014 Night A Night- Covered with HCA, Band7 available for support at any time.

13/08/2014 Day A nurse redeployed to ASU, band 7 in the numbers

15/08/2014 Day A RN out to NHSP. Band 7 available for support.

23/08/2014 Day A RN out to NHSP. Band 7 can be contacted for support.

26/08/2014 Night A RN short out to NHSP. Band 7 can be contacted for support

30/08/2014 Day A RN moved to Aldenham due to lack of staff and replaced with HCA. Band 7 can be contacted for support.

Croxley 10/08/2014 Night A 1XRGN SICK NOCTE-NOT COVERED. Cross cover from Sarratt

11/08/2014 Night A 1 RN NIGHT DUTY OUT TO NHSP/AGENCY cross cover from Sarratt

Gade

02/08/2014 Day A NO CSW FROM 13.00-16.00HRS. SUPPORT FROM HERONSGATE.

02/08/2014 Night A Support from Heronsgate

09/08/2014 Day A Bed manager/senior nurse on call aware. Shift is short. Hca offered for swap with rn but nurse in charge managed with staff on duty

14/08/2014 Night A Agency RN did not attend. Nurse requested to help from Aldenham ward for short period

30/08/2014 Day A one nurse sent to Aldenham ward for a period later returned ward required special for confused patient not available. This decison was made by the senior nurse on call and left the ward short

Heronsgate 16/08/2014 Day A Day Made safe by Gade ward to assist where possible.

23/08/2014 Night A Escalated to bed management

Sarratt 01/08/2014 Night A bank nurse did cancelled. Bed manager informed. Patients divided between RN's to facilitate ratio 1-8

30/08/2014 Day A Support from Croxley

Su

rge

ry

De La Mare 02/08/2014 Day A Ward manager and on-call manager informed

18/08/2014 Day A Beckett closed. We have 12 inpatients and 13 admissions today. Bnad 6 sent home sick. No senior cover. Staffing levels escalated to matron

Langley

10/08/2014 Day A HCA on duty called in sick- agency trained sent from letchmore to cover morning

29/08/2014 Day A Band 7 working clinically for early duty due to trained staff short fall; 2 day one, post operative patients on the ward who would normally have been in ITU - requiring high level of nursing and monitoring. Late part of the duty will require increased staffing.

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Letchmore

16/08/2014 Day A 1x RN & 1x HCA offsick. RN for ESAU moved to Letchmore to cover shortage. Only 1 RN can do I.V.s for Letchmore & ESAU.

18/08/2014 Day A 2 trained nurses sick, 1 RN shift uncovered by nhsp, 2 trained nurses moved to cover. No supervisory today

22/08/2014 Day A One HCA off sick today, ward acuity is high, bed manager and surgical matron made aware will continue to assess.

25/08/2014 Night A One RN short on Letchmore, HCA pulled from ESAU, Ward Acuity currently high with confused clients. Situlation to be discussed with oncall manager.

Ridge 27/08/2014 Day A short of RN on late as one RN only on early. Band 7 supporting clinically

Combined ITU

07/08/2014 Night A Admitted patients unable to increase staffing. Patients on the unit were safe with minor adjustments

28/08/2014 Day A Amber due to acuity of the patients at the time. Level 3 x 13 Level 2 x 5. Escalated to on call manager. Ward nurse was provided to help

28/08/2014 Night A Amber due to acuity of the patients at the time. Level 3 x 13 Level 2 x 5. Escalated to on call manager. Ward nurse was provided to help

31/08/2014 Night A Inadequate staffing levels to cope with current patients/workload. Staff on the shift did manage the patients safely. There was additional pressure as the anaesthetetic team were busy. Outreach was used to support. Matron informed in the am.

Wo

me

ns

& C

hild

ren

s

Pa

ed

iatr

ics

CED

01/08/2014 Day A Short MLD. Starfish aware and Senior sister from Safari can cover. A&E will help if needed.

14/08/2014 Day A Starfish and A&E will help as required.

29/08/2014 Night A x1 night team is on a twilight. Starfish will cover CED in the event of a resus

30/08/2014 Night A x1 MLD finishing at 8pm so night are short until 10pm but A&E and Starfish are aware and to support.

Safari Day Unit

19/08/2014 Day A Agency nurse was booked but was cancelled by agency yesterday afternoon. Student nurse to work early shift and Clinical Facilitator to assist with preop assessments.

20/08/2014 Day A Out to agency, not yet filled-support offered from Starfish Ward.

22/08/2014 Day A Band 7 included in numbers.

Starfish

01/08/2014 Day A Nhsp unable to provide cover, senior management team aware and are able to assist where needed.

07/08/2014 Day A One qualified nurse short of planned level of staffing. Ward full with high level of acuity in the morning. Discharges expected during the day. Risk mitigated by clinical facilitator covering ward and medical / surgical teams providing swift review.

Gy

na

eco

log

y

Elizabeth

01/08/2014 Day A Covered for morning but late will leave only x3 Band 5 as NHSP nurse called in at 07.10. Still out to try and cover for the late. Supervisory supporting clinically

12/08/2014 Day A No Supervisory role today. x 6 electives coming in. 5 medical patients. 1 orthopaedic patient. 4 surgical patients.

15/08/2014 Day A EU nurse awaiting pin number mitigation working as supernumery untrained

22/08/2014 Day A We will be Amber for the late. X2 overseas nurses, 1 with no PIN and the other is on performance management. Band 5 agency nurse on and the outstanding Band 5 is not covered. Supervisory supporting clinically

23/08/2014 Night A 1 RGN off sick. Chief nurse aware and has advised not to put the shifts out to bank unless the bed managers are going to use the beds.

26/08/2014 Day A x 5 electives to come in. x 14 medical patients. X5 surgical patients. When the early shift RN goes home at 5pm this will only leave 3 RNs on the ward, one of these extremely junior. Supervisory supporting clinically

27/08/2014 Day A

x 14 medical patients. X4 surgical patients. Only 3 members of staff on this morning. 2 of these permanent and one agency. One permanent, is very junior overseas nurse. Only 1 HCA and he is agency & 1 HCA on an early. Band 7 is in the numbers in the afternoon. X5 electives to come in, only 1 bed available. Concerns about staffs ability to maintain patient care at a high level due to activity and skill mix.

Ma

tern

ity

Delivery Suite

01/08/2014 Day A 1 x HCA short shift out to nhsp, will redeploy staff

09/08/2014 Night A 1 x HCA short will redeploy and cover from another area

23/08/2014 Day A Informed agencies of vacancies. Staff moved around to accomadate workload leaving 1 RM short on d/s - but safe according to current workload

26/08/2014 Day A 1 rm down on early shift. Band 7 on management day covering this on d/s as d/s busy. Agency rm called no answer

29/08/2014 Night A 2 x RM short on night shift . Have gone out to agency- expected to be filled by the night. Redeployed within division

Victoria 10/08/2014 Night A HCA short will redeploy HCA from another area if needed

ABC

09/08/2014 Night A 1 x HCA short will redeploy and cover from another area

23/08/2014 Day A x 1 RM down as staff moved to accommodate workload in other areas. Staffing level safe according to current workload

27/08/2014 Day A Redeployed all midwife's x3 to help on delivery at 21:00hrs activity high. 2 PN transferd to postnatal ward.

Katherine

01/08/2014 Night A I x nursery nurse short on night duty , shift out to nhsp. Will redeploy from other areas

10/08/2014 Night A HCA short will redeploy HCA from another area if needed

23/08/2014 Day A x 1 RM down on late shift - agencies informed. Also x 1 HCA down on late shift as bank cancelled. Will redeploy staff from other areas if HCA shift not filled

Knutsford 26/08/2014 Day A agency rm called in sick ar 0600. no patients currently on ward. HCA moved to triage as HCA off sick on triage. Agency has found a rm for day shift starting around 10.00 - this rm will be required on d/s unless patients attend for knutsford

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Appendix 4 Current nurse to bed, staff to bed and trained to untrained skill mix. All ratios are rounded to the nearest whole number. The nurse to patient ratio indicates the number of registered nurses required to care for a specific number of patients for example a 1:7 ratio means one registered nurse is required for every 7 patients. This ratio may vary according to the specialty for example critical care patients require one nurse to one patient (1:1) The staff to bed ratio indicates the total number of registered nurses and health care support workers required to care for a specific number of patients in beds. The staff to bed ratio will vary according to the type of ward, acuity and dependency of patient’s, location and ward layout, activity and patient flow. The overall nurse to bed and staff to bed ratio does not take into account where staffing is reduced for example when staff take breaks, usually 1 hour of time per person on each long day and night shift. The actual nurse and staff to bed available to give care to patients during this time is less.

WARDS Current Nurse to patient ratio days

Current Nurse to patient ratio nights

Current Staff to bed days

Current staff to bed nights

Current skill mix

Ridge 1:7 1:10 1:4 1:6 60/40

Langley 1:6 1:8 1:4 1:5 67/33

Cleves 1:7 1:7 1:4 1:6 62/38

Flaunden 1:7 1:7 1:4 1:6 68/32

Letchmore 1:7 1:7 1:4 1:6 68/32

Elizabeth 1:7 1:9 1:5 1:6 67/33

Beckett/ De-la-Mare 1:7 1:9 1:5 1:7 68/32

AAU Green L1 1:5 1:5 1:3 1:3 62/38

AAU Yellow L1 1:5 1:5 1:3 1:3 62/38

AAU Blue L1 1:5 1:5 1:3 1:3 62/38

Green & Purple L3 1:7 1:7 1:3 1:5 61/39

Yellow L3 1:7 1:7 1:3 1:4 68/32

Blue L3 isolation 1:3 1:3 1:2 1:2 62/38

Blue L3 1:6 1:6 1:3 1:4

Bluebell 1:4 1:4 1:2 1:2 51/49

Winyard 1:6 1:6 1:4 1:4 62/38

Red (Surge) 1:6 1:6 1:4 1:5 68/32

Croxley 1:7 1:7 1:4 1:4 56/44

Sarratt 1:7 1:7 1:4 1:5 58/48

Gade 1:6 1:6 1:3 1:4 68/32

Heronsgate 1:7 1:7 1:4 1:5 66/34

Cassio 1:7 1:7 1:4 1:5 68/32

Dick Edmunds 1:5 1:5 1:3 1:3 68/32

Aldenham + HDU 1: 5 1:5 1:3 1:4 76/34

CCU 1:3 1:3 1:2 1:3 90/10

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Appendix 5 Summary of outputs from all review models.

Funded establishment

SNCT benchmark

Professional judgment

Dependency benchmark

Dependency

tool variance

compared to SNCT

Triangulation benchmark

Triangulation variance vs.

funded

Ridge 31.47 32.28 31.47 31.70 -0.58 31.82 -0.35

Langley 20.31 16.74 18.28 20.10 3.36 18.37 1.94

Cleves 26.10 29.23 28.76 24.00 -5.23 27.33 -1.23

Flaunden 31.26 30.08 31.32 35.10 5.02 32.17 -0.91

Letchmore 23.46 23.68 23.54 27.60 3.92 24.94 -1.48

Croxley 38.30 35.37 38.30 28.90 -6.47 34.19 4.11

Sarratt 46.23 51.01 46.23 37.20 -13.81 44.81 1.42

Aldenham 41.87 29.60 44.40 38.96 9.36 37.65 4.22

Gade 23.54 20.88 23.54 23.60 2.72 22.67 0.87

Heronsgate 24.39 25.42 26.10 22.20 -3.22 24.57 -0.18

CCU 23.40 11.38 23.40 28.71 17.33 21.16 2.24

Cassio 23.53 23.23 23.53 22.20 -1.03 22.99 0.54

Dick Edmunds 53.93 45.02 53.93 61.70 16.68 53.55 0.38

Bluebell 41.80 23.04 41.80 41.80 18.76 35.55 6.25

Winyard 26.18 21.85 26.18 20.00 -1.85 22.68 3.50

AAU Green L1 26.14 22.08 26.14 24.60 2.52 24.27 1.87

AAU Yellow L1 26.14 20.91 26.14 24.60 3.69 23.88 2.26

AAU Blue L1 26.14 20.22 26.14 24.60 4.38 23.65 2.49

AAU Green & Purple L3 38.48 30.33 38.48 30.00 -0.33 32.94 5.54

AAU Yellow L3 23.55 17.32 23.55 16.70 -0.62 19.19 4.36

AAU Blue L3 33.96 21.74 33.96 22.10 0.36 25.93 8.03

Elizabeth 30.30 27.29 28.72 31.00 3.71 29.00 1.30

Red (Surge) 23.50 18.95 23.50 20.00 1.05 20.82 2.68

Beckett & De la Mare 33.64 32.70 33.64 34.70 2.00 33.68 -0.04

Total 737.62 630.36 741.05 692.07

61.72 687.83 49.79

Variance

107.26 -3.43 45.55

49.79

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Appendix 6 Strengths and limitations of acuity and dependency tools. As per recommendations, multiple tools were utilised during the review in order to provide balanced assurance. The table below lists the strengths and limitations of each method.

Safer Nursing Care Tool Professional judgment Dependency tool Qualified staff per shift NICE guidelines state that each registered nurse should care for no more than 8 patients per day or there is a risk of increased harm to patients

SNCT does not provide recommendations at shift level, however tool is designed to make provision for sufficient staff per shift

Professional judgment should take account of total establishment needed to meet required qualified staff per shift

Dependency tool does not provide recommendations at shift level, however tool is designed to make provision for sufficient staff per shift

Registered to Unregistered skill mix RCN guidelines recommend Registered to Unregistered ratios between 65:35 and 70:30 and 50/50 – 65-35 in older people

SNCT provides recommendation at total establishment level only does not take into account skillmix

Professional judgment should take account of skill mix split

Dependency tool splits establishment recommendation by qualified and unqualified

Patient throughput / turnover

SNCT has been revised to reflect patient turnover, and AAU specific metrics developed. However generic factors still based on assumptions of turnover

Provides qualitative assessment of staffing requirement to manage average daily turnover

National average staffing per ward, grouped & benchmarked at specialty level

Representative of fluctuations throughout day/ week/ year

Point in time assessment of acuity & dependency; accuracy can be enhanced by repeating for exercise for multiple weeks at regular intervals in the year

Implicitly incorporates average activity/ trends, however this is not quantified or made explicit

Implicitly incorporates average activity/ trends, however this is not quantified or made explicit

Actual patient acuity and dependency

Captures actual acuity and dependency of patients based on critical care scorings, subject to user interpretation

Provides qualitative assessment of staffing requirement to manage average acutiy and dependency

Based on assumed acuity and dependency of patients according to bed base

Actual bed occupancy Provides point in time assessment of actual bed occupancy which may not be representative across the day. Does not take account of actual patient turnover however generic factors build in assumptions of turnover

Provides qualitative assessment of staffing requirement to manage average bed occupancy

The model has the capacity to factor in actual bed capacity which is fairly robust if based on accurate data

Standardised, quantitative approach

Input data subject to interpretation, however validation by senior nurses took place to improve accuracy of capture

Subject to ward manager interpretation, validation from senior nursing team to improve accuracy

Establishment based on benchmarked metrics, subject to user interpretation of ward type

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Appendix 7 SNCT methodology, patient classifications, multipliers and definitions The SNCT captured the acuity and dependency of bedded inpatients at 3pm on weekdays

between June 23rd

and July 11th 2014.

Ward managers allocated each patient a score between zero and three based on Critical Care patient definitions.

Scores were reviewed, validated and challenged daily by a senior nurse.

Scores were multiplied by the factors outlined in SNCT guidelines the sum of the factors provided a recommended daily staffing establishment, reflecting qualified and unqualified nursing staff. An average score was calculated based on the three week period.

Specific recommended multipliers were used for AAU to reflect patient turnover.

All Multipliers were adjusted to reflect the 21.6% uplift applied at WHHT.

An assumption of 100% occupancy was incorporated into the analysis; blanks were allocated a score of zero up to full occupancy and escalation capacity was excluded (i.e. 3 bedded ASU gym).

Supernumerary Band 7s were excluded from the SNCT recommendation and funded baseline.

Adult inpatient AAU

Score

SNCT multiplier

WHHT multiplier*

SNCT multiplier

WHHT multiplier*

Definition Example care requirements

Level 0 0.99 0.99 1.27 1.27

Patient requires hospitalisation. Needs met by provision of normal ward cares

Elective admission; Underlying medical condition requiring on-going treatment; Regular observations (2 - 4 hourly); ECG monitoring; Fluid management; Oxygen therapy < 35%; Single chest drain, Confused patient not at risk; Requires assistance of one person to mobilise

Level 1a 1.39 1.39 1.66 1.65

Acutely ill patients requiring intervention of those who are unstable with a greater potential to deteriorate

Increased level of observations and therapeutic intervention; Oxygen therapy > 35%; Post 24 hours following insertion of tracheostomy, central lines, epidural or multiple chest or extra ventricular drains

Level 1b 1.72 1.71 2.08 2.07

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

Complex wound management requiring more than one nurse or taking more than one hour; Mobility or repositioning difficulties requiring more than two people; Complex Intravenous Drug Regimes; Patients on EoL pathway; Confused patients at risk or requiring constant supervision

Level 2 1.97 1.96 2.26 2.25

May be managed within clearly identified designated beds, resources with required expertise and staffing level, or dedicated L2 facility

Deteriorating/ compromised single organ system; Patients requiring non-invasive ventilation/ respiratory support; CPAP/ BiPAP; Greater than 50% oxygen; Drug infusions requiring monitoring; CNS depression of airway and protective reflexes

Level 3 5.96 5.94 5.96 5.94

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

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Appendix 8 Patient Dependency tool UK benchmarks . Example of nurse staffing from best practice wards in the UK and is based on Activities of daily living dependency data – This method considers ward staff per occupied bed and benchmarks current staffing from a national database and covers 28 specialist wards. This result may not be reflective of the real dependency activity on a given ward.

Medical and Medical Speciality Wards

Jul-13

Wards 185

Enter the occupied beds below in Column H, Row 2.

Optional, you can adjust the time-out (sickness-absence) value in cell H7. N.B. 21% is entered as 0.21 How many days is your ward open (enter your answer here)?

7 days

How many hours is your ward open (enter your answer here)?

24 hours The values in C11 to C18 are the recommended staffing for the ward.

I11 to I18 is the average actual FTEs by grade divided by the number of occupied beds. You can calculate your own in the same way. C20 to C23 recommends 'safe cover' staffing when workload falls significantly.

If you think you've made a mistake then do not 'save' but reload the template and start again. Highlight the range you want to print before printing the results.

Ward Name: Heronsgate

Row Column B C D E F G H

1 Dep.1 Dep.2 Dep.3 Dep.4 Spcld Total

2 Patients 3.1 8.8 5.7 2.4 20.0

3 Patient Mix 16% 44% 28% 12% 0% 100%

4 Hourly mins. 2.1 5 8.5 13.4 6139.5

5 Ratios 1.0 2 4.1 6.4

6 Workload index 3 19 23 15 61

7 Time out 21.6%

8 Breaks 12.7%

9

10 Grade Mix (Band) FTE's Best Practice Competence

Per Bed

11 Total 22.2 100% 101% 1.11

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Appendix 9 Cardiac Care Unit and Level 3 AAU - Current configuration and funded establishment

Ward area No Beds Funded establishment

Current Nurse to bed days

Current Nurse to bed night

Current skillmix

Cardiac care unit 11 24.60 1:3 1:3 90/10

Green purple 27 39.68 1:7 1:7 61/39

Yellow L3 27

59.90

1:5 1:5 68/32

Blue L3 1:6 1:6 62/38

Blue Isolation Suite 6 1:3 1:3

Totals 71 124.18

Cardiac Care Unit and Level 3 AAU - Proposed re-configuration and establishment

Ward area Beds Proposed Establishment

Proposed Nurse to bed days

Proposed Nurse to bed night

Proposed skillmix

AAU L3 - Cardiac care unit 24 37.76 1:4 1:5 79/21

Yellow /Blue L3 30 61.25

1:6 1:6 62/38

Blue Isolation Suite 6 1:3 1:3

* 11 medical beds 11 19.49 1:6 1:6 55/45

Totals 71 118.50

* Previously the Cardiac care unit beds – It is proposed that the 11 medical beds will be managed by the Acute Stroke Unit Nursing team. Financial Information – All identified posts have been costed by finance at mid-point of pay scale

WTE

Cost at mid-point for 12 months Cost for 7 months

Total Savings 5.68 269,488.00 157,201.33

trust board meeting 9 october 2014 - west herts college · 2014-10-03 · trust board meeting 9...

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