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Safe Staffing and Dependency Levels
The Health and Social Care Act 2008 Regulation 18 highlights the responsibilities of providers in ensuring that they deploy enough suitably qualified, competent and experienced staff to enable them to deliver safe, effective and responsive care and support.
Short staffing compromises care both directly and indirectly. Recurrent short staffing results in increased staff stress and reduced staff wellbeing, leading to higher sickness absence which leads to the increased need for more bank and agency staff. This in turn leads to inconsistencies in care and also leads to high staff turnover.
There are many indicators which highlight that providers may be experiencing significant problems with staffing levels such as:
- High sickness rates that are particularly stress related
- Chaotic or disorganised rotas
- Task led duties with no time for engagement or communication with service users, families and professionals
- Over reliance on temporary workers
- Staff inductions that are limited, rushed or absent
- Learning and development is restricted to mandatory training only
All these indicators can have a direct impact on the service users as staff often have no time to respond to calls for help, deliver effective handovers, there is a lack of time to effectively support mealtimes and personal care and increasing the risk of medication errors and incidents such as unwitnessed falls. Insufficient staffing can also impact on the stressed and distressed behaviours of service users.
Safe staffing is more than just having the ‘right’ numbers. The provider must decide the level of staffing required to deliver safe, effective and responsive care and support. There is no one size fits all and providers must review their individual service, the types of people they support and remembering that this may change over time. For example, two 30 bedded nursing homes for people living with Dementia may have different staffing levels according to the individuals needs of the people living there. This should also take into consideration the environment, the use of assistive technology and may change according to the planned activities of the day. Sadly, many providers often set generic staffing levels according to the number of service users/residents rather than promoting a culture of assessing individual needs using validated dependency tools.
Dependency tools can help providers to assess the number of staff required. These tools aim to collate information to assess the dependency of each individual requiring care and support and how many hours of staff support they need. They can also capture the time taken to complete documentation and other administrative tasks. Recognised dependency tools reflect both direct care and indirect care, which is often overlooked such as administrative tasks, attendance at meetings, communicating with families and professionals.
There are many dependency tools in circulation and some providers create their own bespoke tool. Some providers refer to care funding calculators which assess how many hours are required for general tasks and 1:1 care and support, and they ensure that the rotas not only ensure safe staffing levels to undertake the individual hours required but also incorporate additional hours to carry out engagement with service users and other administrative tasks. It is important that providers ensure staff are trained and understand how to use the tool in use.
However, a validated tool alone will ensure that high-quality care and support will also be delivered. Recruiting the right staff with the correct values and behaviours is key along with training that focuses on the individual needs of service users will also enable effective staff deployment. Other methods to support the tool can be used such as observations of communal areas which monitor the experience from a service user’s point of view. I promoted the use of these in both elderly care homes and learning disability settings as they capture not only the level of care and support provided, but ultimately whether this is tasked based or truly meaningful. I advocate that these should be carried out by Registered Managers or senior managers within the organisation to truly understand the impact of staffing levels in their service.
As a previous Quality Director, I personally faced the difficulties educating and promoting the importance of ensuing robust staffing levels. It is important that providers recognise the investment in workforce planning. I personally believe that boards and commissioners should delegate the responsibility to sign off workforce levels in health and social care to the Chief Nurse/Director of Quality/Nursing. Unfortunately, although they advise and are accountable for the quality and safety of care and support, they often have no management responsibility, and this lies with those who hold the budget.
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