At some point, someone is going to ask you to prove that your ward is staffed safely. It might be an internal audit team, your director of nursing, the CQC, or your own board. When that happens, you need to be able to show what your planned staffing levels are, whether you are meeting them, and what you do when you are not.
Running a staffing compliance audit does not need to be complicated, but it does need to be thorough. Here is how to approach it.
Step 1: Confirm your planned staffing levels
Before you can assess whether you are compliant, you need a clear baseline. That means having documented planned staffing levels for every shift on your ward.
Your planned levels should be based on patient acuity and dependency, not just bed numbers. The National Quality Board’s 2016 framework (National Quality Board, 2016) makes this clear: staffing decisions should be driven by the needs of the patients on the ward, reviewed regularly, and adjusted when those needs change.
Check that your planned levels are documented, up to date, and signed off by whoever is responsible for workforce planning in your trust. If they are not, that is the first thing to fix before you audit anything else.
Step 2: Gather your actual staffing data
You need shift-level data showing how many registered nurses and healthcare assistants were actually on duty for each day shift and night shift. This should cover a meaningful time period, typically three to six months, so that you can see patterns rather than just individual shifts.
If you are recording this on paper or in spreadsheets, this is the step that usually takes the longest. You will need to go back through rotas, timesheets, and possibly agency booking records to build up the full picture.
If you use staffing software, this data should already be captured and available to pull as a report.
Step 3: Calculate your fill rates
Fill rates tell you what percentage of your planned staffing you actually achieved. You calculate them by dividing actual hours by planned hours and multiplying by 100.
For example, if you planned 120 registered nurse hours for a day shift and 108 hours were actually worked, your fill rate for that shift is 90%.
You should calculate fill rates separately for:
- Day shifts and night shifts
- Registered nurses and healthcare assistants
This gives you four fill rate figures per day. Aggregating these by week and month will show you where the gaps are.
Trusts are required to report fill rates to their board monthly and publish them to NHS England. If your fill rates are consistently below plan, that is a finding your audit needs to flag.
Step 4: Calculate CHPPD
Care hours per patient day (CHPPD) gives you a standardised way to express how much nursing time each patient is receiving. It is calculated by dividing total nursing and healthcare assistant hours in a 24-hour period by the number of patients at midnight.
CHPPD is useful because it accounts for both staffing and patient volume. A ward could have a 100% fill rate but still have low CHPPD if the patient numbers have increased beyond what the establishment was designed for.
There is no universal target for CHPPD because it varies by ward type. What matters for an audit is that you know your CHPPD, you can show how it has changed over time, and you can explain any significant variations.
Step 5: Review escalation and incident records
A compliant ward does not just track numbers. It also has a clear process for what happens when staffing drops below safe levels. Your audit should check that:
- There is a documented escalation policy
- Staff know what it is and how to follow it
- There is evidence that the policy has been used when needed (for example, records of requests for bank or agency staff, redeployment decisions, or red flag alerts)
- Staffing incidents have been reported through the trust’s incident reporting system
If you find shifts where staffing was below plan and there is no record of any escalation, that is a gap worth investigating. It does not necessarily mean nothing was done, but without documentation there is no way to demonstrate that the right steps were taken.
Step 6: Look for patterns
Individual shifts being understaffed is one thing. The same shift type being understaffed repeatedly is a systemic issue.
When you review your data, look for:
- Wards that are consistently below target. If a ward is regularly hitting 75% fill rates on night shifts, the planned establishment may need reviewing or there may be a recruitment issue that needs addressing.
- Seasonal patterns. Summer holidays and winter pressures often create predictable staffing dips. If the same thing happens every year, it should be planned for.
- Over-reliance on agency staff. High fill rates achieved through heavy agency use can mask underlying recruitment or retention problems. Agency staff also tend to be less familiar with ward routines, which can affect patient safety (Griffiths et al., 2016).
- Correlation with incidents. If patient safety incidents cluster around the same shifts or periods that have low fill rates, that is an important finding.
Step 7: Present your findings
An audit is only useful if the findings lead to action. When you present your results, keep it practical.
Start with a summary: are you compliant, partially compliant, or non-compliant, and against what standard? Then show the data that supports that conclusion. Fill rates by ward, CHPPD trends, any escalation gaps, and any patterns you identified.
Be specific about what needs to change. “We need more staff” is not actionable. “Night shift fill rates on Ward 3 have averaged 72% over the past six months, primarily due to two unfilled registered nurse vacancies” gives the board something they can act on.
Finish with recommendations. These might include reviewing planned establishments, prioritising recruitment for specific wards or shift types, investing in better data capture tools, or updating escalation policies.
Making audits easier going forward
The hardest part of most staffing audits is gathering the data. If your ward records staffing on paper or in spreadsheets, you are essentially reconstructing the picture from fragments every time someone asks for it.
Safer Staffing captures planned and actual staffing at the shift level and calculates fill rates, CHPPD, and utilisation automatically. When audit time comes around, the data is already there in one place, ready to report on.
If you want to see how that works, book a demo and we will walk you through it.
References
Griffiths, P., Ball, J., Drennan, J., Dall’Ora, C., Jones, J., Maruotti, A., Pope, C., Recio Saucedo, A. and Simon, M. (2016) ‘Nurse staffing and patient outcomes: strengths and limitations of the evidence to inform policy and practice’, International Journal of Nursing Studies, 63, pp. 213-225.
National Quality Board (2016) Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time: Safe, sustainable and productive staffing. London: National Quality Board.