Care Home Staffing Is More Than a Number

I delivered leading a safe service workshop this week and we ended up spending quite a bit of time talking about care home staffing, dependency and skill mix. Inevitably dependency tools came up. I have used these for years and they can be really useful, but more recently I have seen the number produced becoming the answer rather than part of the discussion.

If the tool says seven staff, that gives you something to work with, but you still have to think about who those seven people are and what the day actually looks like. Are we also planning for when the GP is in, a family wants to meet with the manager, somebody needs taking to hospital or a resident needs time to sit down and properly review their care plan? Some of the tools being used are primarily calculating care hours, and even then we need to remember the figure is indicative.

The layout of the home makes a difference as well. Seven staff in a small home on one floor is not the same as seven people trying to cover two or three floors, different areas or residents whose needs are spread across the building.

Then you have the make-up of the team itself. You can have seven names on a rota, but perhaps two are new, one is still building confidence and one is back from long-term leave. The number might match the dependency calculation, but the shift can feel very different once you are actually in it.

That is really what Regulation 18 is getting at. It is not just about having enough people on the rota, but having enough people who are suitably qualified, competent, skilled and experienced for the people being supported. Regulation 12 sits alongside that because safe care depends on the team actually having the right skills and competence, not just the right headcount.

One of the managers in the workshop made the point that the people working the shift usually know where the pressure is. I agree with that. They know which mornings are difficult, which residents now need more support than they did three months ago, where confidence is lacking and when the same few people are always the ones being asked to sort things out.

I think staff should be part of the conversation. Not because every staffing decision needs to be agreed by the whole team, but because there is very little value in deciding the staffing model without listening to the people who are actually trying to make it work. I have, however, also heard staff say they are short staffed when I can clearly see there are more than enough people on the shift!

This is where it is important for staff to make sure the information being used to model staffing is accurate. If somebody now takes fifty minutes to support in the morning rather than thirty, but the records still say thirty, the dependency tool is working from the wrong information. The same applies when someone starts needing two staff, needs more support with eating and drinking, becomes less mobile or simply needs much more time and reassurance than they did before.

If that isn't recorded, the data may continue to say the staffing is sufficient even though the people working the shift know it isn't.

There are other signs I would be looking at as well. If incidents are increasing, complaints are coming in, sickness is rising, staff are regularly staying late or the team are consistently saying the shift is no longer manageable, I would want to know whether staffing and skill mix could be part of that. It does not automatically mean more staff are needed, but it should be enough to make us look again rather than assume the previous calculation still fits.

A recent CQC report from a care home in Nottinghamshire is a useful example of exactly this. The staffing levels matched the dependency tool being used, but inspectors still found people were often left without staff oversight in communal areas and some people were left in their rooms for prolonged periods without safety checks. CQC found breaches relating to safe care and treatment, safe and effective staffing and good governance.

That is a pretty clear reminder that the tool saying the numbers are right does not necessarily mean the staffing arrangement is working in practice.

Sometimes the answer will be that the staffing is right and something else needs to change. Sometimes the team needs more training or confidence in particular areas. Sometimes the way work is organised needs looking at. And sometimes the needs of the residents have changed and the staffing needs to change with them.

Dependency tools are only part of the solution when it comes to safe staffing.