Dear Mrs Connor

Re: Mrs Elizabeth Ann Cox - Response to Regulation 28/Prevention of Future Death (PFD)

Thank you for your letter of 12 March 2015 written in accordance with Regulation 28 of the Coroner’s Rules following the conclusion of the inquest that was held touching the death of Mrs Elizabeth Ann Cox.

I note the matters of concern that were raised in your letter, namely:

1. During daytime hours, where additional staff are needed, the Reducing Harm Team can be contacted to try to provide the necessary resources. I was told although this is currently under review, that, as matters stand, this (or an equivalent) is not available during the night.
2. It has been suggested as part of a trust wide review that the number of staff available on the wards at night be reduced – from 3 registered and 2 unregistered currently, to 3 registered and 1 unregistered. I am aware that this is merely a proposal – and not currently in place – but should this come into effect, I am concerned that events like these may re-occur, where staff simply do not have the capacity to look after their patients safely, because of workloads. Our response contains details of action taken or proposed to be taken, setting out the timetable for action as indicated in your letter.

Since the conclusion of the inquest, senior management have considered these areas of concern further and addressed each in turn below:

1. Availability of Reducing Harms Team

It has been acknowledged by the Trust that there are additional needs required due to the increase in frailty and dependency of our patients and the challenges of caring for

2 these patients in en-suite rooms. In response, the Trust has developed a ‘Reducing Harms Team’ to enhance the care given to our most vulnerable patients. This is not a professional or regulatory requirement. The Trust however felt it would help to improve care to this group of patients and have succeeded in implementing this. The Reducing Harms initiative was recognised nationally and nominated for the Nursing Times Awards 2014 making the final of the Improving Patient Dignity Category. The Reducing Harms Team are a team of Unregistered nurses (Health Care Assistants HCA) who have identified that they are comfortable with supporting patients who may have more challenging needs and have received the appropriate skills and training to undertake this role. It is a pool of staff that the Trust allocates on a shift by shift basis depending upon potential risk, particularly in relation to those patients who are at risk of falling or whom have cognitive impairment which could lead to them causing harm to themselves or others. The initiative was introduced in June 2013.

The process for the wards in accessing enhanced care (during the day and at night) is as follows:

1. A risk assessment form is completed on the ward identifying the level of enhanced care that is required.
2. Depending on the ward’s activity and acuity this can often be performed within the established numbers of staff already on duty, using the guidance and techniques suggested and skills and training that the ward teams have.
3. If it is felt that additional resource is required especially for those patients at level 4 (requiring 1-1 observation) then a request can be made to the Duty Nurse Manager for a Reducing Harms Team member to be deployed to either undertake this role or to support the ward in performing this role.
4. As the Reducing Harms Team is currently not available at night, additional staffing that is identified as being required is requested from the Nurse Bank or Agency to ensure this role is still performed.
5. If additional resource to the Reducing Harms Team is required at any time due to the number of patients requiring enhanced care then this is supplemented by the use of appropriately trained bank staff. Implementation of the Reducing Harms Team highlighted the need to ensure all of our HCA’s (bank, agency and substantive staff) are able to deliver enhanced care. All HCA’s receive training on providing enhanced care through their annual mandatory training, with additional training and advice available from the Dementia Nurse Specialist and Falls team. This means that wherever it has been identified that enhanced care is required (through the risk assessment tool) then these needs are able to be met through our substantive workforce regardless of the Reducing Harms team availability.

Our UNIFY staffing return indicates that even though we do not have a dedicated resource for nights we do deliver 1-1 enhanced care whenever a risk assessment has identified the need.

In summary therefore, the Reducing Harms Team was introduced to support our more vulnerable patients as a Trust based initiative. It is a small resource of additional staff who are able to support our existing substantive ward teams in delivering enhanced care. Introducing the Reducing Harms Team had the effect of highlighting the need to be responsive in providing enhanced care for those patients identified rather than simply ensuring the ratio of RN:HCA’s achieved the required standard. Our Health Care Assistant fill

3 rates, which are monitored, reported to the Board of Directors and published at least monthly, show that we employ many additional HCA’s to support patients who have enhanced care needs. We do not refuse a request for additional staff to provide enhanced (1-1) care if the risk assessment (detailed above) indicates the need – day or night.

2. Night Staffing Levels 

Staffing levels, particularly nurse staffing levels, have been under particular scrutiny during regulatory inspections.  As you will be aware, Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 state that: ‘Sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed in order to meet the requirements of this part’.

The intention of this regulation is to make sure that providers deploy enough qualified, competent and experienced staff to enable them to meet all the other regulatory requirements.

The legislation does not indicate what safe staffing levels are and there is no official tool for calculating appropriate staffing levels.

CQC’s guidance ‘Guidance for providers on meeting the Regulations’ (February 2015) state that to meet the requirements of Regulation 18, ‘providers should have a systematic approach to determine the number of staff and range of skills required in order to meet the needs of people using the service’. Providers should also consider, ‘the different levels of skills and competence required to meet those needs, the registered professional and support workers needed, supervision needs and leadership requirements’. The CQC will also consider if staffing levels are regularly assessed to ensure they are sufficient to meet people’s individual needs. The CQC will look to see if providers have taken into account the layout of the building. They also look into the arrangements that are in place for making sure that staff levels have the right mix of skills, competencies, experience and knowledge, to meet patient’s needs.

In June 2013, the Bruce Keogh team (Review into the Quality of Care & Treatment provided by 14 Trusts in England) identified the following concern in relation to nurse staffing at Sherwood Forest Hospitals NHS Foundation Trust;

 The nursing skill mix was a significant concern to the team. ‘The Trust stated that the nurse to untrained ratios were currently 50:50 on general wards The minimum the Rapid Responsive Review (RRR) panel would expect is 60:40 with a preference for 65:35. The above are made significant by the design of the hospital impacting on the ability to provide safe care so staffing levels need to consider the hospital design. An urgent review of the nursing staffing skill mix with immediate plans to ensure that the skill mix in place is adequate to provide safe patient care is needed’.

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The following table demonstrates the changes that have occurred in relation to skill mix and numbers during and following Keogh.

RN Days Numbers HCA Days Numbers RN Nights Numbers HCA Nights Numbers Overall Numbers Prior to Keogh Review – before June 2013 3 3 2 2 3+3 Days 2+2 Nights

The skill mix was 50% RN to 50% HCA This meant that there were too many HCA’s and not enough Registered Nurses on night duty.

Post Keogh / Quality Summit 3 3 3 2 3+3 Days 3+2 Nights

Following the Quality Summit a temporary measure was instigated to increase the number of Registered Nurses on night duty, whilst a full case of need was developed for consideration by the Trust Board.

The skill mix was 50% RN to 50% HCA on days and 60% RN to 40% HCA on nights

New Investment Numbers 5 2 3 1 5+2 Days 3+1 Nights

In January 2014, the Trust Board agreed to an investment of £4 Million into nursing. The main aim was to address the skill mix concerns that had been raised through Keogh. The new numbers and skill mix were agreed for all of our inpatient wards, including Newark and Mansfield Community Hospital.

As part of the case for investment the ward sister was supervisory and not included within these numbers.

This investment enables to Trust meet professional recommendations of 1 RN to < 8 patients and a 70:30% RN:HCA skill mix. Research and evidence suggests the higher number of registered nurses the greater positive impact on outcomes and mortality. It is recommended that the maximum number of patients a RN should care for on night duty is 12 patients. Our current status and the business case proposal gives a ratio of 1 RN to 8 patients. This proposal meets the guidance as established by the Royal College of Nursing and the recent NICE Safe Staffing guidance.

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In order to ensure the recommendations for future staffing levels were accurate and evidence based, a number of approaches were used. These were:

1. Professional Judgement.
2. Telford model across surgical wards.
3. Safer Nursing Care (Acuity and Dependency) Tool, formerly known as Association of UK University Hospitals Tool (AUKUH).
4. National benchmarking toolkits.

In formulating this future model for nurse staffing levels, consideration was given to a number of important factors, which included case mix, clinical service plans and the layout and geography of each of our wards. There are limited tools that assess ward layouts, but within the literature it is acknowledged that more staff are required as more side rooms are included within designs. The 50% bay / side room design of our wards was been factored in within the professional judgement model. The case of need also reflected on the research undertaken across the Magnet hospitals. There are currently 389 Magnet accredited hospitals in the US. Magnet is a recognition programme that acknowledges excellence in nursing services. The framework is based around transformational leadership, structural empowerment, exemplary professional practice, new knowledge, innovation and improvements and empirical quality results.

There is a growing body of research which indicates that Magnet hospitals have higher percentages of satisfied registered nurses, lower registered nurse turnover and vacancy, improved clinical outcomes and improved patient satisfaction. In more recent studies a lower (up to 14%) mortality rate has been noted. Researchers have identified that the better outcomes in Magnet Trusts could be attributable to investments in highly qualified and educated nurses, alongside practice environments that support the delivery of high quality care. Magnet Trusts also have higher staff retention and reduced rates of burn-out across nursing.

The National Nursing Research Unit undertook a meta-analysis of 96 studies and found consistent evidence of an association registered nurse staffing levels and patient outcomes (2013). Many of the outcomes which will be positively influenced by an investment in nursing staff were highlighted in our case for investment.

It was identified within the case for investment that it would take 3 years to move from a 50/50 skill mix to the proposed 70:30 skill mix and the new numbers as described above. This is because an additional 100 Registered General Nurses (RGN’s) would be required to alter the skill mix.

Current position

We are currently in the second year of this change model. Due to successful recruitment of RGN’s for our surgical wards, we are currently implementing the staffing model of 5+2 on days and 3+1 on nights.

New Investment Numbers 5 2 3 1 5+2 Days 3+1 Nights

This meets professional recommendations of 1 RN to < 8 patients and a 70:30% RN:HCA

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As this staffing model meets professional expectations the CQC (visit scheduled 16th June
2015) are likely to commend us on moving towards these professional recommendations.

Our medical wards have not been as successful with nurse recruitment. This is a national problem but the Trust has developed and is currently driving a nurse recruitment strategy to recruit more Registered Nurses. Our medical wards, including the ward in which Mrs Cox was cared for, are currently being maintained on the post Keogh numbers as described below.

Post Keogh / Quality Summit 3 3 3 2 3+3 Days 3+2 Nights

The skill mix is 50% RN to 50% HCA on days and 60% RN to 40% HCA on nights

The medical wards will not move to the new proposal until the required registered nurses numbers (circa 100) have been recruited. It is anticipated this may take a further 12 months.

Requests for enhanced care and 1-1 support will continue to be supported when required. During this period of change the Trust Board and the Quality Committee continue to robustly monitor the staffing levels and the impact upon quality and safety.

I hope the above provides assurance that the Trust does have the strategies to assess and address staffing based upon capacity, safety and workload.