HEALTH AND SOCIAL CARE COMMITTEE
General Scrutiny Session – Chief Nursing Officer (CNO)
Date: 30 January 2014
Venue: Senedd, National Assembly for Wales
Title: General Scrutiny Session
Purpose
1. As part of the Health and Social Care Committee programme of scrutiny of health professionals, Professor Jean White, Chief Nursing Officer (CNO), has been invited to attend the Committee on 30 January to explore the priority areas within her remit in order to scope any possible future Committee work on nursing. The Committee has requested an update on specific work being led by CNO and her team to ensure appropriate nurse staffing levels in hospitals and other settings.
2. This paper provides an overview of the priority areas of work which are being pursued by the Nursing Directorate either currently or planned for in the financial year 2014/15.
Nursing Directorate Priority Work Areas
3. Health Care Standards/Fundamentals of Care
As a response to the Francis Inquiry, the Minister for Health and Social Services made a commitment to review of the Standards for Health Services in Wales (2010) and the Fundamentals of Care (2003) policy. The work will achieve a unified set of standards for people across health and in partnership with social care. The standards will be constructed to enable Welsh Government to monitor performance and quality service delivery based on a consistent outcome based approach. The standards will be aligned with professional, Royal Colleges, and NICE quality standards, as well as National Service Frameworks, National Cancer standards and equivalents, and other regulatory and accreditation requirements. The project will commence in January 2014 for completion April/May 2015.
The Fundamentals of Care Audit tool was revised in 2013 and has been used to gather the 2013 audit data from an expanded number of clinical areas. Board reports arising from the 2013 round are expected in March 2014. The findings from this round of audits will be reviewed and themes or areas of concern will inform future national work. In previous years this had led to national work, eg on oral health and hygiene, and foot, nail and hair care.
4. Nursing Care in the Care Home Sector
A collaborative project is currently being planned to develop a programme of inspections in partnership with Care and Social Services Inspectorate Wales (CSSIW), Health Boards, Healthcare Inspectorate Wales (HIW) and Community Health Councils (CHC) which will:
· Provide CSSIW/HIW/Health Boards (and thereby the public) assurance as to the quality of nursing care in relation to delivering on the fundamentals of care.
· Check that CSSIW’s new inspection processes are sensitive to failures in the fundamental standards of care and to identify how inspections could be strengthened.
· Understanding the profile of the quality of care being provided and importantly understand the scale and nature of risk within the sector.
· Highlight best practice.
· Understand what drives good practice, the barriers to improvement and the causes that lead to unsatisfactory care.
· Work closely and interface with the All Wales Fundamentals of Care Steering Group.
5. Service User Experience
A multi-disciplinary National Service User Experience (NSUE) Group was established in October 2012 to develop a framework for measuring and reporting on the views and experience of service users, and for capturing how this information is used to inform and improve service delivery. This group reports to CNO.
The Framework was formally issued to Chairs of NHS organisations by the Minister for Health and Social Services in May 2013. It identifies core principles to underpin patient experience work and determines three themes of service user experience:
· First and lasting impressions, including dignity and respect
· Safe, supportive environment
· Involvement and understanding of acre
The Group has also developed a set of core questions for organisations to use to assess service user experience as part of the Framework. The core questions were issued to NHS organisations in July 2013 and first reports were submitted in September. There was noticeable variation in the range of information provided which made it difficult to fully determine the utilisation of the core questions and any resultant improvements to services across Wales. A second round of data has been requested for January 2014.
The NSUE Group has agreed the following top three priorities for 2014-15:
· Share core questions results and board reports to drive consistency and quality of collection, analysis and reporting.
· Development of reporting templates and methods to triangulate patient feedback from all sources, including complaints and identification of improvements
· Work to develop methods for:
o Children and young people,
o Mental Health
o People with communication difficulties.
6. Advanced Practice
Advance practice roles are central to the development of new ways of delivering services and utilising the full skills of staff. The Government has already supported these roles by developing a framework for advanced practice and guidance on developing a portfolio to help staff and their employers determine whether they are practising at an advanced level. There is a current research project, commissioned by the Welsh Government, being undertaken by Workforce Education Development Service (WEDS) workforce research fellow (hosted by Cardiff University) to explore the role, preparation and clinical supervision of Advanced Practitioners in the NHS in Wales. The findings of this research are expected in 2014 and will be considered by the CNO.
In the academic year 2013/14, WEDS commissioned 68 master level programmes and 211 clinical masters level modules in the following areas: emergency medicine, unscheduled care, neonatal and paramedics. This was the first time central government funding has been used. Budget for this year is £250,000.
7. Learning Disability Nursing
The UK CNOs initiated a UK wide modernising learning disability nursing programme in 2012, which will run until 2015. Wales plays an active part in the development work which is set out in the document ‘Modernising Learning Disability Nursing - Strengthening the Commitment’.
The Learning Disability Care Bundle was co-produced by service users, carers and clinicians and launched in the Senedd on 13 January 2013. It sets out key steps to be taken to ensure that all people with a learning disability are able to access dignified, person centred care within general acute healthcare settings.
The bundle will be delivered under the 1000 Lives Plus improvement service and sets out key steps to ensure:
o Early recognition of patients who have a learning disability
o Effective communication with patients, carers, family members and clinicians
o Patient centred care
o Effective review and discharge planning
Following the piloting work in Abertawe Bro Morgannwg UHB, the Care Bundle will now be rolled out across Wales. A named individual has been identified in each health board to champion the delivery of the Care Bundle.
On
14 January a stakeholder event was held to consider what further
needs to be done to improve the care of people with a learning
disability in hospitals. Under consideration is:
o The introduction of health passports;
o Using an identifier for patients with a learning disability similar to the butterfly symbol used in some hospitals for patients with dementia.
One of the work streams being developed by the Learning Disability Advisory Group is to consider the social determinants of health and health inequalities for people with a learning disability. Specific activity related to this is yet to be determined.
8. Health Visitor Review
Following a review of health visiting services in 2012/13, CNO is
leading the implementation of the recommendations from the review
through an all Wales stakeholder group. This work is nearing
completion and includes:
o The development of an all Wales Healthy Child Programme of which child health surveillance will be component part.
o An All Wales common assessment tool for Health Visitors and their teams.
o An All Wales Parent Held Child Health Record.
o A review of IT systems with a longer term plan to introduce electronic records.
o Development of an appropriate staffing and workforce tool to deliver safe and effective Health Visiting services, based on workload and caseload profiling.
o Provision of appropriate levels of safeguarding training and clinical supervision for all Health Visitors and their teams.
9. School Nursing
To support the delivery of school nursing services that promote and improve the health and well-being of school-aged children and young people performance measures have been developed in collaboration with a group of School Nurses. Following consultation with a wider group of stakeholders during February/March 2014, discussion will take place with Health Boards Nurse Directors around how these measures can be used to ensure continued development and improvement of services.
A commitment to the universal provision of public health nursing to all school age children was embedded in the One Wales manifesto commitment in 2009. Whilst the commitment was to children identified as having special needs and educated in state secondary schools there was no reference made to children educated in special schools. Because of this a review of the health needs of children in special schools in Wales was commissioned by the CNO in June 2013 and completed in November 2013. We are now waiting for the Ministerial decision on the next steps in implementing the recommendations.
10. Revalidation
The Nursing and Midwifery Council (NMC) is required to introduce some form of revalidation for nurses and midwives by December 2015. Proposals suggest this will be a significant change to the current re-registration requirements.
The office of the CNO is engaged in the stakeholder groups set up by the NMC to deliver this project and provides a Welsh perspective to these discussions. The regulation of nurses and midwives remains a non devolved issue. The NMC is currently consulting on its proposed approach to revalidation which includes some form of third party confirmation as to a nurse or midwives competence to remain on the NMC register.
11. Healthcare Associated Infection (HCAI)
Nurse Directors take the executive lead for infection prevention and control (IPC) within NHS organisations but it is understood that eliminating infection is ‘everyone’s business’. In December 2013 Team Wales met to focus exclusively on HCAIs and the challenges ahead. Over the last 10 years there has been significant reduction in HCAIs across Wales, but we need to go further and faster recognising that HCAI is not just a secondary care issue but one that extends across all healthcare environments.
In 2014 the office of the CNO along with policy colleagues will work with Public Health Wales and Health Boards to:
o Develop and promulgate to the health service in Wales a ‘code of hygiene’ (working title) which is effectively a set of core standards essential to improving infection prevention and control (IPC) which we will expect every healthcare organisation across Wales to adopt and fully implement
o Improve access to and uptake of training and education in IPC including the launch of a new e-learning module – accessible to all staff not just nursing staff
o Publish new guidelines in IPC for care homes
o Adopt new ‘measures of success’ – Tier 1 ‘targets’ addressing reduction in HCAIs across the HB population (previous ‘targets’ have focused on reductions in inpatients) and further develop indicators relating to IPC within the nursing metrics and nursing dashboard
o Adopt a standardised approach to root cause analysis (RCA) of HCAI and the development of an all Wales RCA tool
o Drive the roll out of 1000 lives HCAI initiatives such as the ‘STOP’ campaign
o Promote and monitor the widespread adoption of HCAI care bundles
o Develop more robust systems for surveillance - facilitating the adoption of IT systems to improve data capture and feedback to clinicians and national surveillance
12. Aligning Nursing Skills Framework
Patients frequently have complex health needs and ensuring the nursing staff have the skills and competence to meet their needs is essential. In July 2012 the Chief Nurse and Nurse Executives Wales agreed a work plan with the objective of nurses having the ability to identify and care for patients within their clinical areas who may have additional specific needs without the requirement of transferring them initially to the relevant specialist area e.g. a diabetic patient within a mental health setting, or a patient with dementia in an acute care setting.
This work plan has delivered an All Wales Governance Framework for Aligning Nursing Skills for all registered nurses in Wales. This framework sets out a structured Continuing Professional Development (CPD) cycle that enables strategic planning, and that identifies personal transferable skills needs. Within the framework examples are used to highlight where and how it can be utilised.
To support the framework the work plan has also delivered a portfolio for staff to use. The portfolio can be used as a medium for integrating practice, supervision, mentorship, peer review, reflection and performance review. Again while this is a generic portfolio there is an expectation that local patient need will drive the personal transferable skills needed.
The work for 2014 includes finalising guidance and principles on mentorship, preceptorship and rotational models and rolling out the framework.
13. Post Registration Career Framework for Nurses
In 2013 the Welsh Government’s Post Registration Career Framework for Nurses (2009) was reviewed. The review included a number of focus groups as well as a questionnaire to front line staff and managers from across Wales. Recommendations from the review are currently being considered. It is likely that the framework will be relaunched in 2014, as this coincides with the 10 year anniversary of moving to all graduate pre-registration nursing in Wales.
14. Professionalism Work
In 2011, following the publication of reports highlighting failures in care, such as those by the Patients’ Association and the Older Peoples’ Commissioner for Wales, CNO commissioned a report specifically to examine professionalism in nursing in Wales.
The report was co-ordinated and written by Professor Melanie Jasper, Swansea University, and involved extensive discussion and engagement with nurses and midwives across Wales. Multiple methods were used to address specific questions in this report. The report was presented to the CNO in December 2012. Given the report had implications for individuals, service, education and government, the report was circulated amongst key stakeholders seeking their feedback. In 2013, following consultation on the recommendations in the report, three clear themes were identified as priorities for development in 2014:
o Support for professional/clinical leadership.
o Appraisal/PDR process.
o Clinical Supervision
A project plan is being developed by a new member of staff. However a number of existing work streams will inform the implementation of the three recommendations including the review of clinical leadership being conducted by the Welsh Government deputy chief medical officer and the Nursing and Midwifery Council (NMC) work on revalidation.
15. Midwifery/Maternity Care
Following implementation of the Vision for Maternity Services in Wales in 2013, the focus of activity is on monitoring performance. The Chief Nursing Officer chairs six-monthly performance board meetings individually with the seven Local Health Boards. Organisations are required to demonstrate performance against Wales Maternity Services outcome indicators and NHS performance measures to show continuous improvement in maternity services.
Staffing Levels
16. Midwifery Staffing Levels
Through the bi-annual performance meetings with Health Boards assurance is sought that the workforce levels are in place for Birth Rate Plus Compliance. This is the minimum staffing level required for maternity wards to provide safe levels of service.
17. Nurse Staffing Levels
Quality and safety are a key priority for the Welsh Government. While there is evidence of excellent care provided to many patients every day, it is crucial that Welsh Government ensures lessons are learnt from the finding of the Francis Inquiry. Health Boards are expected to ensure that their services are both safe and of a high quality.
The Government has committed to assist NHS Wales on this agenda and this has been reinforced by the Minister in his July 2013 response to the Francis Inquiry when he stated the Welsh Government’s commitment to providing the tools for the determination of the right numbers of nurses.
“This also means having ways to determine the right staffing levels to meet patients’ needs. The implementation of acuity tools in acute medical and surgical settings for nurse staffing will be rolled out next year. A programme of work will be in place to extend this to other settings.” (Delivering Safe Compassionate Care WG 2013)
He also identified in his response the allocation of £10 million (recurring) to assist Health Boards to address this important issue.
The Chief Nursing Officer and the Executive Directors of Nursing have been working on nurse staffing levels for acute adult medical and surgical wards since early 2012. A number of acuity tools have been tested to ensure the right skill mix and skills to meet the patients’ needs. The selected tool is now being tested and will be ready for roll out in Wales by end of March 2014.
In the interim a series of principles for nurse staffing levels are being worked towards by Health Boards. These are:
o Professional judgement will be used throughout the planning process.
o Nursing establishments on acute wards should not normally fall below 1.1 wte/bed including a head-room of 26.9% (to allow for annual leave, training etc).
o For specialist areas and wards with tertiary services, professional standards, guidelines and national frameworks should be used to determine nurse staffing levels e.g. National Stroke Nurse Staffing Standards (2007), Quality Requirements for Adult Critical Care in Wales (2006) etc.
o Numbers of patients per Registered Nurse should not exceed 7 by day.
o The skill mix of Registered Nurse to Nursing Support Worker in acute areas should generally be 60/40.
o The Ward Sister/Charge Nurse should not be included in the numbers when calculating patients per Registered Nurse.
The prioritisation of work on acuity tools for other clinical areas has also been led by the Nurse Directors and the CNO through their forum. Work on priorities has been delegated to various groups.
For 2014/15 the following priorities have been set for the development of acuity tools.
1. Adult acute in-patient environments.
2. Community environments (district nursing and health visiting primarily).
3. Mental Health in-patient environments.
Each group has an Executive Nurse Director as a sponsor. It is anticipated that once the adult acute tool goes live in April 2014 other clinical areas will request a tool. Therefore prioritisation for other areas was considered in March 2013 and it was decided that emergency departments, paediatrics, learning disability, and neonatal nursing would be the next areas for acuity tool development.