1. How to ensure the right people, with the right skills, are in the right place at the right time
Hazel Richards
Deputy Chief Nurse
NHS England North

2. Published in December 2012

3. Action Area 5: ‘ensuring we have the right staff, with the right skills in the right place’

4. Wider Policy
Context

5. Francis Recommendations
Evidence to the inquiry suggested that the Trust did not have reliable nursing establishment figures – NICE to develop evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix – Nurse ward managers should operate in supervisory capacity, visible to patients and staff, role model and mentor – Seek and record the advice of Nursing Director on quality and safety on major change

6. The Keogh Review
Issues related to nurse staffing in some organisations identified by reviewers:
dissonance between nursing establishments, staff in post and staff available on each shift
inadequate staffing levels on night shifts and weekends
poor skill mix
links to Compassion in Practice Action Area Five Workstream
Feedback from people involved in the reviews
Some of the organisations reviewed were counting Assistant Practitioners as part of the Registered Workforce

7. Berwick Recommendations
Government, Health Education England and NHS England should ensure that sufficient staff are available to meet the NHS’s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported’ ‘Boards and leaders of provider organisations should take responsibility for ensuring that clinical areas are adequately staffed in ways that take account of varying levels of patient acuity and dependency, and that are in accord with scientific evidence about adequate staffing’ Reference to NICE work and to staffing ratios

8. Hard Truths
Department of Health response to the Francis Inquiry Hard Truths. The Journey to Putting Patients First; includes the requirement for that:
‘from April 2014, and by June 2014 at the latest, NHS Trusts will publish ward level information on whether they are meeting their staffing requirements. Actual versus planned nursing and midwifery staffing will be published every month; and every six months Trust boards will be required to undertake a detailed review of staffing using evidence based tools’.

9. Key Objectives of Action Area Five
Directors of Nursing to agree appropriate staffing levels through the application of evidence based tools
All nursing and midwifery staffing levels and quality experience metrics should be discussed at a public board meeting
Boards to sign off and publish evidence based staffing levels at least every six months, providing assurance regarding the impact on quality of care and patient experience
Monitoring of compliance (CQC, NTDA, Monitor, Contracts)
Work with NICE to establish adequate and appropriate staffing levels for all care settings
These were the original objectives laid out in the implementation plan

10. Key Objectives of Action Area Five
Develop Good Practice Guidance with National Quality Board
Undertake an assessment of ward or community nurse / midwifery leaders having a supervisory role
Directors of Nursing to undertake a review of options for each patient being allocated a named key nurse responsible for co- ordinating care
HEE leading the on values / HCSW workstreams (linked to Cavendish Review)

11. National Quality Board Guidance
Available at:

12. Good Practice Guidance
National Quality Board guidance published on 19/11/13
Includes ten expectations and twenty case studies
Six themes –
Accountability and responsibility
Evidence-based decision making
Supporting and fostering a professional environment
Openness and transparency
Planning for future workforce requirements
Role of commissioning
Work in progress with CQC regarding the monitoring of implementation of the expectations
Developed in partnership with a range of organisations including:
NHS England
HEE
NICE
CQC
NHS TDA
Monitor
Applies to all care settings
Use of the term Capacity and Capability acknowledges that staffing is not just about numbers
There is no ‘one size fits all’ approach to establishing nursing, midwifery and care staffing capacity and capability, and this guide does not prescribe a single approach to doing so. Neither does it recommend a minimum nurse-to-patient ratio. The intention is that this guidance is followed by all health care providers in all health and care settings, so it would not be appropriate to indicate a number or ratio that should be applied, as we recognise that the staffing needs will vary in relation to each particular setting and the complexity of care provided. It is the role of provider organisations to make decisions about nursing, midwifery and care staffing requirements, working in partnership with their commissioners, based on the evidence, the needs of their patients, their expertise and knowledge of the local context. This will be discussed and explained in public and reviewed by the Care Quality Commission (CQC) as part of their inspection regime.
There has been much attention in the media about where things have gone wrong but the inclusion of case studies highlights where things are working well.

13. Accountability and Responsibility
Boards take full responsibility for the quality of care provided to patients, and as a key determinant of quality, take full and collective responsibility for nursing, midwifery and care staffing capacity and capability.
Processes are in place to enable staffing establishments to be met on a shift-to-shift basis.
Expectation one – came primarily from Francis Inquiry. It talks about accountability with Boards taking full responsibility for quality of care delivered and that this should not just rest with the Director of Nursing, rather it should be the responsibility of the whole Board.
We have identified that they must ensure robust systems and procedures exist, that they assure themselves and account for publically that they are operating with safe high quality staffing levels. They must also be mindful not to simply move the problem or cost saving to another part of the workforce, causing a detrimental effect elsewhere within the system.
Expectation 2 came as a result of learning from the Keogh Reviews: it makes further reference to the systems and processes that need to be in place, providing boards with the ability to ensure safe and high quality care is delivered through appropriate staffing levels on a shift by shift basis. Therefore requiring focus in real-time monitoring to take account of annual leave, absence, unplanned activities and a change in skill mix as a result of back-filling to meet the immediate shortfall. It also talks about the need for a system of escalation, so that staff, have real clarity about how and when to escalate issues arising from a staffing shortage.

14. Evidence-Based Decision Making
3. Evidence-based tools are used to inform nursing, midwifery and care staffing capacity and capability.
Expectation 3 was set out as a priority in Compassion in Practice this time last year and focuses on the use of evidence based tools as part of the determination of appropriate staffing levels and in the monitoring of actual staffing levels. It requires that staff who are responsible for setting and monitoring staffing levels in planning and real time situations, are adequately trained to use these tools in conjunction with all other available data and soft intelligence to support their decision making and escalation processes. It has resulted in the further development of the AUKUH & now SNC Tools, the updating of the metrics and multipliers. We back the use of the RCM Birth Rate Plus tool and this has been recently updated as well.

15. Supporting and Fostering a Professional Environment
4. Clinical and managerial leaders foster a culture of professionalism and responsiveness, where staff feel able to raise concerns.
5. A multi-professional approach is taken when setting nursing, midwifery and care staffing establishments.
6. Nurses, midwives and care staff have sufficient time to fulfil responsibilities that are additional to their direct caring duties.
In expectation 4, we explore in more detail the conditions needed to support staff in raising concerns about staffing levels and when they fear high quality care could be compromised. It talks specifically about the role of leaders within the system, who must use their professionalism and responsiveness to create and encourage culture and environment where staff, feel genuinely supported and able to speak without fear of reprisal if they feel they are unable to deliver the level of care that is expected by patients or if they see poor practice as a result of this. The key message here is about the balance between providing support for staff to speak up and also for ensuring that staff, understand their own personal responsibility and accountability to take ownership of speaking up.
The theme of expectation 5 is that of collaboration with others parts of the organisation, to ensure that the whole picture is being considered and reviewed to provide a multi-disciplinary approach is taken. The aim of this is to make best use of the resources available and also to provide the best possible experience and outcome for our patients. This is about Directors of Nursing being in the driving seat but that they work with everyone and have the support of their board.
Expectation 6 talks about the other activities that we need to enable nursing, midwifery and care staff time to engage in, from mentorship and continued professional development to supervision and supervisory roles. It requires those setting staffing levels to proactively plan for these indirect but equally essential tasks and to factor this in when determining shift by shift requirements. There is no prescribed whole time equivalent” supervisory sister or charge nurse role, because it is completely dependent on the size and the nature of the ward.

16. Openness and Transparency
7. Boards receive monthly updates on workforce information, and staffing capacity and capability is discussed at a public Board meeting at least every six months on the basis of a full nursing and midwifery establishment review.
8. NHS providers clearly display information about the nurses, midwives and care staff present on each ward, clinical setting, department or service on each shift.
Expectation 7 builds on the priorities within expectation 1, specifically focusing on the need for transparency. So in addition to taking collective responsibility for knowing their required and actual staffing levels it provides that boards must review and publish this data every 6 months on their website, discuss it at a public board meeting and be able to account for any deviation from their evidence based requirement at this meeting. The key here is pro-active management.
Furthermore, in expectation 8 we continue the openness and transparency theme with organisations being required to show very clearly in each ward, unit or patient facing place their current staffing levels and key points of contact or escalation, for patients, visitors and staff. There are many hospitals now learning from Salford, but it isn’t just for acute settings. It can equally apply for The ‘Living Room to Board Room’ in a community setting.

17. Planning for Future Workforce Requirements
9. Providers of NHS services take an active role in securing staff in line with their workforce requirements.
Expectation 9 concentrates on the active role of the board and the organisation in seeking to recruit, train and retain good staff, making every effort to meet the requirement and manage any shortfall. It talks about the need to work closely with their local education and training board (LETB), their regulators and local commissioning groups to develop a future workforce planning forecast to assist with their mid-term strategy for on-going recruitment.

18. The Role of Commissioning
10. Commissioners actively seek assurance that the right people, with the right skills, are in the right place at the right time within the providers with whom they contract.
Finally, in expectation 10 we are focused on the role of commissioners in assuring themselves that providers are actively seeking to recruit, develop and retain good staff and are proactive in the management of any staffing shortfall. It requires them to satisfy themselves that providers are working with appropriate staffing numbers and skill mix to ensure they have the capacity and capability to deliver high quality care. CCG Nurses have a vital role to play here.

19. Workforce Planning Tools
Tools for Acute Care: Safer Nursing Care Tool guidance and multipliers updated in July Available at: nurses/safety-nursing-care-tool Work in progress to develop Safer Nursing Care Tool for AMUs / A&E / Children’s In-Patients / Older People’s care IPAD-APP in development to record SNCT acuity and dependency scores at the bedside and generate local reports – proof of concept stage
Ann Casey and Paul Fish will provide more details on this during their session later today and specifically about how the tool has been used to determine staffing levels within UCHL

20. Workforce Planning Tools
Tools for Maternity: Birthrate Plus - RCM published updated guidance in autumn Tools for Community: QNI have undertaken a review of existing tools (publication pending) Work being taken forward with NHS England Community Nursing Strategy Programme

21. Workforce Planning Tools
Tools for Mental Health Two workshop sessions held Pilots of Dr Keith Hurst and NHSScotland tools Literature review commissioned Tools for Learning Disabilities Initial literature review undertaken Working with MH group on tools for in-patient settings (pilot as above) Focus on tools for LD care in community settings (nursing and social care workforce)
The Mental Health workstream is focused on bringing together the right staffing numbers, with the right competency and capability mix to create a therapeutic environment to care for service users
Considering quality metrics
Learning Disabilities workstream concerned with health and social care workforce and levers to ensure implementation in all care settings where NHS funded care is provided

22. the tools in practice