Evidence from the Royal College of Nursing – HIW 15

Royal College Of Nursing

Response to Health and Social Care Committee’s short Inquiry into the work of Healthcare Inspectorate Wales (HIW)

ABOUT THE ROYAL COLLEGE OF NURSING (RCN)

The RCN is the world’s largest professional union of nurses, representing over 400,000 nurses, midwives, health visitors and nursing students, including over 23,000 members in Wales. The majority of RCN members work in the NHS with around a quarter working in the independent sector. The RCN works locally, nationally and internationally to promote standards of care and the interests of patients and nurses, and of nursing as a profession. The RCN is a UK-wide organisation, with its own National Boards for Wales, Scotland and Northern Ireland. The RCN is a major contributor to nursing practice, standards of care, and public policy as it affects health and nursing.

The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies.

Nurses are supportive of an effective regulator however the regulator needs to be seen as credible and independent? There is a perception that inspectors have a lack of up to date clinical expertise. What systems does Health Inspectorate Wales have in place to ensure that its own staff are able to maintain their expertise and registration and are properly supported and trained so that they are clear what their role and remit is and know what to look for.

Regulators and inspection bodies should support nurses in their call for appropriate staffing within their organisations. We would like to see Welsh Government set mandatory skill mix and staffing levels and HIW to use these standards within their regulatory model. Evidence from extensive studies and the experience of recent investigations into patient safety show a strong correlation between adequate staffing levels and poor quality of care. Workforce indicators can therefore act as a warning sign for compromised care, and should therefore be an important part of HIWs monitoring and inspection process. HIW should look at Health Boards workforce plans to ensure they are supported by relevant and reliable data. We are increasingly seeing reports of inappropriate staffing such as nurses without a children’s qualification being employed to make up numbers. The Royal College of Paediatrics and Child Health document[1] states that Emergency Departments (EDs) receiving children should have a children’s lead nurse and one children’s nurse per shift. The RCN[2] states that this is the ideal standard but is not currently being met. An audit of current numbers in South Wales was carried out to examine current compliance and some units are not meeting current recommended standards.

We would question whether HIW has access to workforce data on a ward by ward and shift by shift basis to ensure that unsafe staffing is not masked. The RCN has produced comprehensive guidance on safe staffing levels, with a number of separate publications for specific settings.[3] The RCN will shortly be producing an updated policy statement on safe staffing and workforce planning, recommending the use of the following staffing indicators, broken down at a ward and shift level:

· Nurse staffing relative to patients

· Skill mix (including ratios of registered to unregistered staff, banding/experience of staff, and appropriate levels of nurses with specialist skills in certain clinical areas).

· Actual nursing staff relative to planned establishment

· Rates of staff sickness

· Staff turnover

· Use of agency/bank nursing staff

· Supernumerary status of ward sister/manager

· Appraisal rate

We would recommend that Health Inspectorate Wales should have access to this information and publicly report on these indicators.

The RCN believes that the inspections are vitally important as they allow the regulator to spot problems and also act as a deterrent. Inspection must include unannounced visits at various times of the day and night. Inspectors must be able to talk to a range of staff, including both junior and senior staff and ensure that staff are able to speak freely.

Our members have welcomed the proposed statutory duty to report concerns about an adult at risk of abuse in the Social Services and Wellbeing (Wales) Bill, and feel that a statutory duty to report would help to continue to improve the culture around whistle blowing. Our members however remain concerned about how they should proceed in situations which they feel are becoming unsafe, but where no serious incident has yet occurred. Health Inspectorate Wales need to explore how concerns with regard to such situations might be reported and investigated.

[1] Services for Children in Emergency Departments 2007

[2] Maximising Nursing Skills in Caring for Children in Emergency Departments 2010

[3] RCN, Guidance on safe nurse staffing levels in the UK, 2010. RCN, Safe staffing for older people’s wards: RCN full report and recommendations, 2012. RCN, Defining staffing levels for children and young people’s services: RCN standards for clinical professionals and service managers, 2013.