enc 9 human resources/organisational development report - northumbria healthcare nhs ... ·...

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Enc 9

Human Resources/Organisational Development Report Purpose of report [For information/discussion/approval]

EWE ☐

Report to: Board of Directors Date: 28 January 2016 Presented by: Executive Director of HR/OD Prepared by: Ann Stringer/David Thompson

Enc. 4

Sickness absence is at 4.54% for December 2015 which is slightly lower than the previous year (December 2014 was reported at 4.83%). The Trust was reported as having the lowest SAR % in the Region in the latest (Q2 - 2015/16) Regional Benchmarking exercise for the second quarter in a row. The Trust has been chosen as one of 10 national Health and Wellbeing exemplar sites. Work continues on promoting a positive organisational culture which an update is provided in Appendix I as an update following the presentation to the Trust Board in January 2015. An update to the Trust board regarding progress made relating to the actions required for Fit and Proper Persons Regulations (FPPR) is attached as Appendix II). The Workforce Report gives an overview of the key strategic areas of assurance, workstreams/associated action plans and progress to date within key areas.

Trust Board are to be assured that CQC/NHSLA requirements are met (other than as below). The EWTD Compliance report is included within this quarter’s report. Trust Board is required to note that in accordance with the new CQC regulation (5) – The Fit and Proper Person’s Regulations (FPPR) is now in place. Due to operational pressures there is an emerging risk that the Trust will be non-compliant for appraisal completion at the end of the reporting year (March 2016). This is an issue to do with operational pressures on medicine and Surgery Business Units. Discussions are taking place.

This report has previously been presented at:

Workforce Committee ☐

The topics included in this report were discussed at workforce committee on the 15th October 2015. The paper was not presented.

Finance, Investment & Performance Committee

Integration Committee

Safety & Quality Committee Patient Feedback sub-committee Workforce Committee Executive Management Team

Executive summary

Risks associated with

this report

Assurance Framework reference

The following Board Assurance Framework references cover this report 1.5, 2.10, 2.20, 2.21, 2.22, 2.30, 5.3 to 5.18.

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Northumbria Healthcare NHS Foundation Trust Workforce Strategy Report to the Board of Directors, January 2016 Date of Sub-committee Meetings: 15th October, 19th November, 15th December 2015 & 21st January 2016 1. Minutes are located on the Trust intranet 2. Our key strategic performance questions cover the following areas:

- Creating a learning environment for quality and continuous improvement - Providing excellent patient centric customer service - Management and maintenance of robust HR policies and systems for safety and compliance.

3. Creating a learning environment for quality and continuous improvement: Key Strategic Questions A. What development opportunities are we providing for our staff to improve their performance and drive a culture of continuous improvement? We have run a variety of organisation development update of programmes since the last Board update as shown below together with an expanded number of activities to support NCUH. Organisational Development Programme Activity October – December 2015

Organisational Development Programme Activity October – December 2015

Programme Number of Sessions

Number of NHCT

Participants

Number of NCUH

Participants

Other/ Wider NHS Network

Assessment Centres Oct – December 2015 6 40 0 0

Consultant Recruitment Panel Training – AIS 2 1 1 0

Continued Professional Development for OSM/GM/DD

0 0 0 0

Clinical Leadership 1 9 3 0

Psychometric reports in October 16 posts 26 login’s

used 23 login’s

used 0

Psychometrics reports in November 15 posts 35 login’s

used 10 login’s

used 7 login’s

used

Psychometrics reports in December 24 posts 36 login’s

used 9 log in’s

used 0

Consultant 5 Day Programme 2 22 4 0

Consultant Appraisal Skills 2 7 23 0

Chaplaincy Team Event 1 11 0 0

Clarity Training 7 19 0 0

Junior Doctors Development 2 29 7 0

LEA (Leadership Effectiveness Analysis) 1 5 0 0

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Safeguarding Team Development 1 5 0 0

Safeguarding Conference (Hot Topics) 1 123 0 0

SAS Doctors Advanced Human Factors 2 10 1 16

SAS Effective Communication Skills 2 8 6 8

Staff Nurse Leadership Programme Cohort 4 2 29 0 0

ThinkSafe 9 6 0 34 Patients

Trust 17 Strategic Leadership Programme 3 38 9 6

TOTAL: 99 459 96 71

B. What transformation activities are the transformation team currently completing (or plan to complete in the next three quarters) that demonstrate continuous improvement is taking place within our work place? The outpatient project has been discussed by David Thompson at a Board development session. Progress is hindered as there seems to be a lack of engagement at various levels in the organisation Referral management system- this work was commissioned by the CCG and is now live in 8 specialties Histopathology review is nearing completion Work has been undertaken to support the improvement of recruitment time lines and the development of Stepchange (referred to later in this report). Assistance is also being provided to move to the shared service for Occupational health with Northumberland County Council. C. What benchmarking or other information do we have in terms of the development of our culture? We are in the early stages of the culture pilot with Monitor and the CQC. A separate Board briefing was provided in January. We have the quarter 2 friends and family test results as shown below:

NHCFT Score

National Rank out of 239 National Rank Qtr 2 2014/15

Recommend as place of care 90% Joint 41

st

47th

of 245

Recommend as a place of work 72% Joint 18

th

10th

0f 245

PHEEM Results

PHEEM is a validated research tool aiming to measure the postgraduate clinical teaching and learning

environment for hospital based junior doctors (Roff, McAleer and Skinner, 2005). This survey has

been used previously with junior doctors following each rotation; however, the Medical Education

Board felt that it was important to extend this survey to include other training grades of staff also. The survey was completed in November 2015. The completion rate was 22%.

Overall, the survey indicated that respondents viewed the postgraduate clinical teaching and learning

environment as “More positive than negative but room for improvement” when assessed against the

ratings listed in the PHEEM research tool. This is shown in Table 4:

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Role Autonomy Teaching Social Support Overall

0-14

Very poor 0-15 Very poor 0-11 Non-existent 0-40 Very poor

15-28

A negative view of one's role

16-30

In need of some retraining

12-22

Not a pleasant place

41-80 Plenty of problems

29-42

A more positive perception of one's job

31-45

Moving in the right direction

23-33

More pros than cons

81-120

More positive than negative but room for improvement

43-56

Excellent perception of one's job

46-60

Model teachers

34-44

A good supportive environment

121-160

Excellent

Table 4 Overall Totals by Sub Scale, Grade and Site

Sub Scale

Average Total by Site

Average Total

NSECH WGH NTGH Trustwide

Perceptions of

role autonomy

32.91 37.14 42.14 35.00 36.35 [Junior Doctor Oct 2015 Result: 43.00] Overall Classification for Sub Scale: “A more

positive perception of one’s job”

Perceptions of

teaching

35.82 41.00 45.00 41.80 40.26 [Junior Doctor Oct 2015 Result: 47.95] Overall Classification for Sub Scale: “Moving in

the right direction”

Perceptions of

social support

26.36 31.29 32.71 28.00 29.16 [Junior Doctor Oct 2015 Result: 32.60] Overall Classification for Sub Scale: “More pros

than cons”

TOTAL: 95.09 109.43 119.85 104.8 105.77 [Junior Doctor Oct 2015 Result: 123.52] Overall Classification: “More positive than

negative but room for improvement” Staff Survey The staff survey for 2015 closed at the end of November 2015. Our response rate was 78.4% which is 4% lower than last year. The survey period coincided with the preparation for and time during the CQC visit and returns during this period were markedly lower. The average response rate for Acute Trusts who used Picker as their survey provider was 38%. We are currently awaiting the weighted outcome data which is under embargo.

4. Providing excellent patient centric customer service: key strategic questions A. How does our HR & OD service support provision of excellent patient centric customer service in relation to training? NMC Revalidation

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Work is well underway to support registered nurses to successfully complete re validation which commences in April 2016. Training attendance has improved following a briefing session to Business Unit managers in the Workforce committee. Statutory & Mandatory Training Work continues to ensure that we deliver the agreed Learning and Development plans using a range of blended learning methods. The Learning and Development Team, in collaboration with the lead trainers have offered flexible and bespoke learning events and activities to individuals and groups across the organisation and specifically on site at The Northumbria. The Care Certificate The Care Certificate Programme continues to be delivered to all new Nursing Assistants and continues to receive excellent feedback. 117 staff completed the Care certificate programme successfully from the introduction in December 2104 to the end of December 2015. The Trust is exploring the options to roll the care certificate out to other staff groups who interact directly with patients and to Nursing Assistants joining our staff bank. A further update on this will be provided next quarter Apprenticeships and Undergraduate/Postgraduate Training Programmes Apprenticeships New cohorts of Apprentices, have been recruited in both Business Administration and Health. Recruitment has also been completed for our undergraduate and postgraduate training programmes with new trainees recruited for Finance, HR and General Management, trainees will undertake work placements and commence the appropriate academic programmes as agreed with the University. Work Based Learning for Staff Following a comprehensive submission to Northumbria University and following a full day interview on 23rd September 2015, the Trust was awarded credit equivalence validation for a proposed BSc (Hons) Degree in Health and Social Care Leadership (Level 6) programme. This programme will commence In May 2016 and we believe that we are the first NHS Trust in the country to be able to offer a full work based academic pathway to employees from level 4 - level 7 with 50% of the programme delivered by the Trust and validated academically. T rust representatives were commended by the panel for the innovative approach to meeting the organisations needs as an employer and that this type of approach could also help facilitate meeting our wider workforce needs such as pre-registration programmes for nurses/social workers with a different set of skills/portfolio to meet the needs of delivering new models of care and this will be explored in more detail going forward.

b) How does our HR/OD service support the provision of excellent patient centric customer service in relation to recruiting the right staff? Values based recruitment Evaluation has been completed in relation to initial panel feedback, initial candidate feedback and predictive validity. All outcomes were positive other than “the process allows them to recruit the right person for the role” which had reduced from last year. However 68% indicated that the questions were relevant for the post. Further work will be carried out to understand this more fully as well as simplifying the paperwork and scoring. Recruitment Performance Following difficulties in meeting the demand for recruitment prior to SECH opening we have worked with the transformation team to improve the speed of recruitment. We have also fully commissioned the Stepchange recruitment management system which allows us to track our performance throughout the key stages of the recruitment journey at both individual applicant and collective level. We will be producing business unit reports from next month. This level of information will allow us to work systematically through the bottlenecks to reduce transactional processing times and turn round of panel packs from interview etc.

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This month’s performance at Trust level is as shown below: Stepchange Report

Task JUL AUG SEP OCT NOV DEC Status 07-Dec-15

Adverts processed 158 156 135 154 127 114 Requisitions in progress 154

Interviews processed 149 136 119 120 123 161 Vacancies in progress 49

Offer Letters issued 161 212 186 167 311 272 Pre-Employment Checks 528

Contracts issued 175 197 274 253 279 217

Start dates agreed 292 256 324 190 354 230

Month

Average of Requisition

approval to start date

Count of

starters

Jul 10.6 4

Aug 14.7 22

Sep 15.0 101

Oct 18.2 139

Nov 18.4 181

Dec 18.2 116

Total 15.9 563

Note: These figures are only for

starters who were offered a post

from 1st July 2015 onwards

Stepchange Report - Recruitment Statistics

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c) Recognising the link between the health and wellbeing of our staff and the care delivered to patients. Health & Wellbeing The health and wellbeing programme continues to go from strength to strength with key highlights from the Health and Wellbeing programme over the last quarter include:

• We devised a comprehensive proposal for the Healthy NHS Workforce programme, which has been approved by NHS England. They have granted us £97,996.29 to support specific projects, including the roll out of the NHS Health Check to eligible staff, a new health trainer post and healthy weight programmes. The Trust Board has agreed to match fund £77,996.29.

• Representatives from NHS England, Department of Health and the Behavioural Insights Team visited the Trust to assess and make recommendations in relation the food environment. We will be taking part in a trial in 2016.

• A Health and Wellbeing Stakeholder Group has been established to oversee the action plan. Dr Jamie Brown has been identified as a senior clinical champion for health and wellbeing.

• We ran a Beat the Board challenge in October, which saw teams across the Trust complete as much physical activity as possible over a two-week period in a bid to score more average points than the Board. 267 staff members actively took part (34 teams) and feedback was excellent, with 63% reporting improvements in team morale and 63% reporting an increase in activity levels. The Staff Health and Wellbeing Coordinator presented on this at an NHS Employers Health and Wellbeing Leads network meeting, and a case study is also being shared at a national level via Northumberland Sport.

• The Staff Psychology and Counselling Service delivered lunchtime mindfulness sessions to approximately 50 staff in the lead up to World Mental Health Day (10th Oct).

• A new health and wellbeing portal was launched on the intranet – it includes information on the health and wellbeing programme (including health promotion information), an Occupational Health section and a HR section (Health at Work policy).

• The Health and Wellbeing Officer delivered a stress awareness session to the Preceptorship Programme, as well as an overview of the health and wellbeing programme to the Northumberland Mental Health Promotion Steering Group.

• A new ‘People’ branding has been approved for the health and wellbeing programme. • The Trust supported the Stoptober campaign with articles in the Staff Update (signposting to cessation

services), screensavers and text on TV screens in the hospitals. • We ran stalls in the ‘health and wellbeing zone‘ at the Trust’s Nursing and Midwifery Conference in

October. • Cancer Research UK ran roadshows at Cobalt and Wansbeck to raise awareness of cancer prevention.

The Trust is very proud to have been chosen as one of 10 national exemplar sites for Health and Wellbeing in the NHS. The Occupational Health, Health Psychology and HR Team are meeting with NHS Employers to progress this work and share best practice with exemplar sites and a further updates will be provided on progress in the next report.

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Seasonal Flu Vaccine Uptake (Frontline Healthcare Workers - All Trusts) 2014/152015/16

NHS England Cumbria & North East

Period:

Organisation:Please use the following file name when

saving this file

Contact Name

Contact email address

Contact Phone number

(B) Number in (A) vaccinated

since 1st Sept 2015

(C) % in (A) vaccinated since 1st

Sept 2015

All Doctors (excluding GPs) 596 333 55.9%

GPs Only

Qualified Nurses, midwives and health visitors

(excluding GP Practice Nurses)

2,763 1,014 36.7%

GP Practice Nurses

All other professionally qualified clinical staff, which

comprises of:-

Qualified scientific, therapeutic & technical staff

(ST&T),

Qualified allied health professionals (AHPs)

Other qualified ST&T

Qualified ambulance staff

Support to Clinical Staff, which comprises of:-

Support to doctors & nurses

Support to ST&T staff

Support to ambulance staff

Support to GP staff

Total (Calculated by system) 6,274 3216 51.3%

#N/A

624 472 75.6%

5. Number of Health Care Workers and Number Vaccinated by Occupation

Laura Mckenna

[email protected]

0344 811 8111 x2639

Enter comments hereComments

January 2016 (Cummulative data from 01 Sep 15 - 08 Jan 16)

RTF - NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST

2,291 1,397 61.0%

Occupation

(A) Number of HCWs involved in

direct patient care on day of data

extraction.

Seasonal Flu Vaccine Uptake

Choose OrganisationChoose a Period

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Sickness absence results The Trust's SAR% for Q3 – Oct-Dec 2015/16 is 4.30% which although is an increase on Q2 (3.60%) is consistent with the normal seasonal increase for this quarter and is lower than Q3 for 2014/15 (4.71%). The last 12 months rolling sickness absence results are as shown in the table below:

The NHS operating framework has stipulated an absence target of 3.5% for this financial year which at present we are not achieving. Targeted Action plans have been developed in each business unit to continue managing this closely during 2015/16. The 12 month RYA for the Trust is now at 4.04% which is a significant reduction over the last 12 months. The introduction of the new Health at Work Policy will also assist in helping support and manage sickness absence going forward. Sickness Absence Rate Benchmarking Data The Trust also participates in a Regional Benchmarking exercise and the 2015/16 Quarter 2 data (Jul-Sep 15) received recently is as follows:

NHCFT are again the lowest in the Region with a 2015/16 Q2 average of 3.63% compared to an overall Regional average of 4.45% and consistently had the lowest monthly SAR % between April – September 2015.

JanuaryFebruar

yMarch April May June July Augus t

Septem

berOctober

Novem

ber

Decem

ber

Absence Rate % 4.97% 4.58% 4.17% 3.85% 3.71% 3.50% 3.56% 3.68% 3.59% 4.03% 4.34% 4.54%

Trust Target 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

12 Month AVE % 4.97% 4.77% 4.57% 4.39% 4.26% 4.13% 4.05% 4.00% 3.96% 3.96% 4.00% 4.04%

4.97%4.58%

4.17%3.85% 3.71%

3.50% 3.56% 3.68% 3.59%4.03%

4.34%4.54%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%Si

ckne

ss %

Organisation Quarter 1 Quarter 2 Quarter 3 Quarter 4 Average

Northumbria Health Care NHS Foundation Trust 3.72 3.63 3.68

Newcastle Upon Tyne Hospital NHS Foundation Trust 3.81 3.70 3.76

County Durham & Darlington NHS Foundation Trust 4.35 3.93 4.14

North Tees & Hartlepool NHS Foundation Trust 4.10 4.45 4.28

Tees, Esk and Wear Valleys NHS Foundation Trust 4.43 4.33 4.38

North Cumbria University Hospital 4.30 4.56 4.43

South Tees Hospitals NHS Foundation Trust 4.44 4.44 4.44

Gateshead Health NHS Foundation Trust 4.65 4.47 4.56

City Hospitals Sunderland NHS Foundation Trust 4.68 4.68 4.68

Northumberland, Tyne and Wear NHS Foundation Trust 5.08 5.02 5.05

South Tyneside NHS Foundation Trust 5.74 5.28 5.51

Average 4.48 4.41 0.00 0.00 4.45

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Regional Analysis of Short Term/Long Term Sickness Absence In the most recent round of Regional Benchmarking (for Q2 2015/16) a further analysis was undertaken to compare the ratio of Short Term Sickness and Long Term Sickness in each Trust participating. The results are interesting and show Northumbria’s Short Term Absence equates to 32.87% and Long Term Absence equates to 67.13% of the total Sickness Absence Rate. The Trusts Short Term % has increased and Long Term as decreased from Q2. It also shows that although Northumbria’s Short Term % Rate is not one of the lowest (although still below the Regional Average), our Long Term overall % Rate is the lowest in the Region (by 0.20%) so it would appear that our management of Long Term Sickness is currently the reason why we have the lowest overall Sickness Absence % rate in the Region.

Labour Turnover Labour turnover is currently at 9.75% (Headcount); 8.63% (FTE) compared to last quarter’s 9.24% (Headcount); 8.52% (FTE). This remains low.

Organisation

Short Term

% Rate

Long Term

% Rate

Total %

Short Term

%

Long Term

Northumbria Health Care NHS Foundation Trust 1.19 2.43 3.62 32.87 67.13

Newcastle Upon Tyne Hospital NHS Foundation Trust 1.08 2.63 3.71 29.11 70.89

County Durham & Darlington NHS Foundation Trust 0.99 2.97 3.96 25.00 75.00

Tees, Esk and Wear Valleys NHS Foundation Trust 1.30 3.00 4.30 30.23 69.77

South Tees Hospitals NHS Foundation Trust 1.28 3.07 4.35 29.43 70.57

North Tees & Hartlepool NHS Foundation Trust 1.30 3.15 4.45 29.21 70.79

Gateshead Health NHS Foundation Trust 1.30 3.21 4.51 28.82 71.18

North Cumbria University Hospital 1.34 3.29 4.63 28.94 71.06

City Hospitals Sunderland NHS Foundation Trust 1.44 3.23 4.68 30.77 69.02

Northumberland, Tyne and Wear NHS Foundation Trust 1.23 3.83 5.06 24.31 75.69

South Tyneside NHS Foundation Trust 1.37 3.91 5.28 25.95 74.05

Average 1.26 3.16 4.41 28.60 71.38

Labour Turnover by Business Unit - Jan 2015 - Dec 2015

319 CHIChild Health

Directorate

319 CLIClinical

Support

319 COMCommunity

BusinessUnit

319 CORCorporate

Services

319 MEDEmergency

Care andMedicineBusiness

Unit

319 SUREmergency

Surgery &Elective Care

Business

Unit

319 ESTEstates and

Facilities

319 StaffBank

319zNorthumbria

HealthcareFacilities

Managemen

t Ltd

319zNorthumbria

Primary Care

LTR Headcount % 10.36% 12.01% 7.84% 9.21% 8.79% 8.15% 11.79% 11.58% 7.92% 14.75%

LTR FTE % 10.11% 11.38% 7.29% 9.04% 8.55% 7.56% 11.87% 0.00% 6.18% 14.18%

Trust LTR FTE % 8.63% 8.63% 8.63% 8.63% 8.63% 8.63% 8.63% 8.63% 8.63% 8.63%

Trust Headcount LTR % 9.75% 9.75% 9.75% 9.75% 9.75% 9.75% 9.75% 9.75% 9.75% 9.75%

0%2%4%6%8%

10%12%14%16%

LTR Headcount %

LTR FTE %

Trust LTR FTE %

Trust Headcount LTR

%

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5. Management and maintenance of robust HR policies and systems for safety and compliance. Key strategic questions a) What is our local compliance with regulatory standards such as CQC and NHSLA frameworks. For 2016 we continue with our approach and communication for statutory and mandatory training has been to ensure each department has targeted department set dates for statutory and mandatory training and appraisals to be completed and the relevant managers and business units will be held accountable for their performance at Workforce Committee. The Business Unit’s report to Workforce Committee on their progress and the performance dashboards have been amended to reflect this approach. In summary based on the current plans and declarations made for Quarter 3 are as follows: Overall Compliance as at 31/12/15 Statutory & Mandatory Training 82%. Appraisal 67.8%

Regulatory Standard: Relates to: Compliance:

Statutory/Mandatory Training NHSLA/CQC

Appraisal CQC

Internal audit outcomes N/A All audit outcomes completed

Notable practice areas Not applicable N/A

Exception reports: None this quarter N/A

Appraisal in Surgery and Medicine BU is well below their trajectory and this has previously been raised in Trust Board issue reports. As a consequence completion against CQC standards has been marked as partial compliance. Operational pressures are the root cause and recovery plans are currently being formulated in business units. Fit and Proper Persons Test Other than completing a review of job descriptions which is underway this work is now complete and systems and processes are in place. HR Risk Register The HR risk register provides positive assurance that key controls are in place and that there are no gaps in controls or assurances (other than as shown in the risk register) to the best of the knowledge of the committee. Outstanding actions and persons responsible are as shown in the committee minutes. Appraisal will be raised at the forthcoming Workforce Committee in January. There have been no new audit outcomes for HR Industrial Action by Junior Medical Staff Discussions continue at a national level between NHS Employers and the British Medical Association (BMA) relating to a proposed new contract for Junior Doctors. The first period of industrial action has now taken place with 2 more scheduled stoppages for the remainder of January and the beginning of February. An all-out stoppage is planned for the 10th February with no emergency cover being provided. Reliance on bank and agency staff

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A total of 18718 bank shift requests were filled and worked in Q3 (Oct-Dec 2015) which is a reduction on Q2. Of these 96.8% were undertaken by the Trust's Bank Staff and 3.2% were undertaken by Agency Staff. There has been a further significant reduction in Agency shifts from Q1 and Q2 (593 shifts as opposed to 926 in Q1 and 658 in Q2). Work continues to improve the quality and availability of temporary staffing within the Trust and also manage the supply of agency staffing required by the Business Units. For the 96.8% of Bank shift requests worked 80% of those who worked the shifts are also substantively employed by Northumbria. The remaining 20% are employed by Northumbria as bank staff only.

Requested Shifts Filled Oct-15 Total By Bank By Agency

Trust Total 6718 6543 175

Requested Shifts Filled Nov-15 Total By Bank By Agency


Requested Shifts Filled Dec-15 Total By Bank By Agency


Combined Total for Q3 Oct-Dec 15

Requested Shifts Filled Q3 Total By Bank By Agency

Trust Total 18718 18125 593

96.8% 3.2%

This detail should provide assurance to the Board that 80% of bank staff also have a substantive contract with the Trust. In line with the recently published guidance from Monitor “Use of framework agreements for the supply of agency nurses” the Trust’s agency supply is in line with the approved framework agreements published. Monitor have recently announced new framework arrangements to reduce agency costs and encourage agency staff to work substantively in the NHS. This includes reducing the amount Trusts are allowed to pay in agency staff costs per hour. One reducyion has already taken place with a further reduction in February. The Trust is reguallary in breach of these price caps currently. Nationally, there is work to agree a lower contract price with approved agencies. The Trust do have an action plan to try and locally reduce agency costs. Quality Improvement Project relating to Temporary Staffing

20%

80%

Bank and Bank/Substantive Contract Analysis - Oct - Dec 2015

Bank Only Bank and Substantive

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Progress continues on the Quality Improvement Project reviewing temporary staffing within the Trust. A dedicated Temporary Staffing Manager is currently being recruited to the Trust and the support team for temporary staffing is currently going through major organisational change in order to facilitate support to clinical teams 7 days per week as agreed by the Executive Management Team. It is expected that these changes and any subsequent recruitment required will be completed within the next 8 – 10 weeks. The project team is now working on additional recruitment to support temporary staffing requirements over winter and flexible approaches to recruitment such as annualised hours are being implemented to support temporary staffing requirements. Appraisal completion At the end of Q3 for 2015/16, compliance is standing at 67.8% (as at the end of December 2015) which is behind plan. There are 266 departments who have not achieved over 85% by the end of December 2015 (104 of which have achieved less than 50% of their appraisals). Action plans will be put in place to ensure these departments reach compliance as soon as possible. 242 departments have achieved over 85% (154 of which have completed 100% of their appraisals). NSECH pressures have adversely affected some completion against BU plans as did the large scale movement of staff due to reconfiguration of services on all sites post NSECH. The Business Unit Breakdown is as follows:

Business Unit Appraisal %

Child Health 78.0%

Clinical Support 76.3%

Community 80.5%

Corporate Services 80.5%

Estates & Facilities 80.6%

Medicine 63.2%

Surgery 63.9%

Staff Bank 17.3%

NHFML 66.7%

NPC 51%****

Trust Total 67.8%

WHISTLEBLOWING INFORMATION

Quarter 3: October – December 2015

During Quarter 3 there were 8 ‘whistleblowing’ concerns raised. Reference numbers have now been added

to ensure traceability of cases.

Information is based on formal whistleblowing concerns or concerns raised via another route where the

reported concern would fall within the whistleblowing definition.

Ref Business Unit Nature of Concern (as defined by whistleblowing policy)

Raised as a formal whistleblowing concern

Action Taken

RC27 NPC other No Case Closed Concern over staffing Informal Investigation – future plans relayed to individual raising concern -

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no further action

RC28 Estates & Facilities

other No Case Closed Concern over staff member behaviour Informal Investigation – concerns shared with individual and confirmed in writing – no further action

RC29 Corporate Services

other No Case Closed Nature of concern - Trust not recouping finance from external source, An informal investigation has been completed and appropriate actions have been taken.

RC30 Surgery other No Case Closed Concern over a specific recruitment process. Formally investigated, concern raised not substantiated.

RC31 Surgery Compromising patient care

No Case On-going Investigation commenced. Case Manager review scheduled 14.01.2015

RC32 Estates & Facilities (NHFML)

Fraud or financial irregularity

No Case Closed Formally investigated and resolved via the disciplinary process – individual dismissed

RC33 Surgery other No Case Closed Concern over a specific recruitment process. Informal Investigation – no further action

RC34 Surgery Compromising patient care

No Case On-going Letter from staff to management team - discussed at EMT action plan being developed

Quarter 2: July – September 2015

During Quarter 2 there were 4 ‘whistleblowing’ concerns raised. Reference numbers have now been added

to ensure traceability of cases.





Action Taken

RC23 Clinical Support (incident occurred Quarter 1 – 2015/16)

Endangering the health or safety of any individual

No Case Closed Behaviours/cleanliness/standards - Informal investigation - issues being followed up via an action plan

RC25 Corporate Services


No Case Closed Informal Investigation – no

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evidence of wrong doing. no further action

RC26 Estates and Facilities

Other No Case Closed The allegations in this complaint have been covered in a separate disciplinary investigation and were considered as part of the outcome of that case

RC1 Medicine (incident occurred Sept 2010 before whistleblowing records commenced but was closed in Quarter 2 – 2015/16)


Yes Case Closed Informal Investigation - no further action

Quarter 1: April – June 2015

During Quarter 1 there were 3 ‘whistleblowing’ concerns raised.





Action Taken

RC21 Estates & Facilities (incident occurred Quarter 4 - 2014/15)


No Case closed informal investigation - referred to disciplinary procedure – employee dismissed

RC22 Clinical Support Fraud or financial irregularity

No Case closed informal investigation - referred to disciplinary procedure target date for completion 29.07.2015

RC24 Estates & Facilities


No Case closed informal investigation currently ongoing

Summary: April 2015 – December 2015

Number of concerns 15

Quarter: - Quarter 1 - Quarter 2

3 4

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- Quarter 3 8

Business Unit: - Child Health - Clinical Support - Community - Corporate Services - Estates & Facilities - Medicine - Surgery - NPC - NHFML

0 2 0 2 4 1 4 1 1

Nature of concerns: - Compromising patient care - Ill treatment of a patient by a member of staff - Fraud/Financial irregularity - Corruption, bribery or blackmail - Criminal offences - Failure to comply with legal/regulatory obligation - Miscarriage of justice - Endangering the health & safety of any individual - Endangering the environment - Deliberate concealment - Other

2 0 4 0 0 0 0 3 0 0 6

All cases from 2014/15 and Quarter 1 of 2015/16 are now closed. EWTD Compliance Further work continues with our EWTD assurance reports. Detailed analysis of the content of the reports has been undertaken by staff within HR Records/Workforce Systems with representatives from the Business Units. This has resulted in some detailed amendments being required within the reports. A EWTD Working Group has now been established and monthly meetings are now in place, commencing 27th January 2016.

6. Equality & Diversity Update Following last quarters report the Trust has agreed four new Equality Objectives to be delivered from April 2016 until March 2019. There is an agreement to work with partners in the Local Authorities, CCGs and VCS organisations in our locality on a consultation process with local communities. These objectives will be published on the Trust website and progress will be monitored through Workforce Committee and publicised annually in the Trust Equality Information Report and EDS2 as part of the mandatory requirements in the standard NHS contract. In addition the Trust has been selected as a finalist in the Colleges & Learning providers category of the 2015 North East Equality Awards. 7. Step Into Health Programme - Promoting NHS Careers to Armed Forces Service Leavers and Veterans.

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The quality of services that NHS organisations provide to patients and carers relies heavily on attracting and retaining the very best individuals, who embody the value of the NHS, to work within it. One particular group of individuals where there is significant potential for transferability into the healthcare sector is with Armed Forces Service Personnel who are actively leaving the service (of which there are currently 15,000) and veterans who have already left. There are many similarities between the values, beliefs and transferrable skills of the armed forces and those within the NHS. By raising the profile of healthcare roles and career pathways the armed forces can be supported to identify opportunities for a future career with the NHS. Norfolk and Norwich University Hospitals have been working in partnership with the Royal Foundation, Walking with the Wounded and the Career Transition Partnership, to develop an Armed Forces Attachment Programme (Step Into Health) that offers service personnel who are in the process of transitioning from service to civilian life, and veterans, the opportunity to gain an understanding of the NHS and the career opportunities it offers. These men and women receive support to undertake an individualised work attachment programme, which assists their integration back into employment and community life. The programme includes: • Information Days • Bespoke work attachment programmes ranging from ½ a day to 4 weeks tailored to their expertise, experience and skills. Due to the success of the programme Health Education England has approved the partnership’s proposal of setting up a network of regional employment coordinators in five other hospitals, of which Northumbria Healthcare NHS Foundation Trust (NHCFT) is one, to support ex-military personnel into working for the NHS by rolling out the Step into Health Programmes regionally. NHCFT’s programme commences on the 2nd February, the first of 6 information days to be held during 2016. Our programme will be a one day, bi monthly, information session; as well as giving an overview of the NHS and the Trust (which will include hospital tour, departmental visits) will give access to career information and guidance with the aim to provide a clear insight into the breadth of opportunities available within NHCFT. Following attendance at the information day delegates will be given the opportunity to apply for a work experience placement; these will be designed and offered on an individual basis. These individuals will be better placed to apply for positions or apply for higher education. This is an excellent opportunity for the NHS to ‘tap into’ a large talent pool. Following the implementation of the Step Into Health within NHCFT, the aim is to raise the profile of the programme locally within other NHS organisations and with external agencies across the region. 8. Recommendation to the Board of Directors Trust Board is asked to note the contents of this report. ANN M STRINGER DAVID THOMPSON Executive Director of HR/OD Non Executive Director

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Appendix II

Risk Assessment of the Actions Required to meet compliance with the FPPR

Area Actions required Individual responsible Level of risk

assigned (RAG)

Comments

New Appointees

Search of insolvency and bankruptcy register Ann Stringer (Human Resources) Completed

Search of disqualified directors register Ann Stringer (Human Resources) Completed

Evidence of values based recruitment Ann Stringer (Human Resources) Available to use for Directors

Remuneration/Nomination committee minutes available (showing evidence of debate, decisions, reasons for decisions and any recommendation to the Council of Governors (for NEDs) or the Board of Directors (for EDs) this may included that an individual may be appointed to a role based on their qualifications, skills and experience with the expectation that they will develop specific competence to undertake the role within a specific timeframe.

Ann Stringer (Human Resources) Claire Riley (Communications and Corporate Affairs)

Remuneration/Noms committee minutes available – template to be devised to ensure future full compliance with FPPT

Self-declaration of fitness including explanation of past conduct/character issues (where appropriate)

Ann Stringer (Human Resources) FPPT declaration completed

Amended reference request template to cover full requirements of Regulation 5

Ann Stringer (Human Resources) New template completed

New contract of employment template for new appointments

Ann Stringer (Human Resources) New template completed

Existing Appointees

Remuneration/Nomination committee minutes available (showing evidence of debate, decisions, reasons for decisions and any recommendation to the Council of Governors

Ann Stringer (Human Resources) Claire Riley (Communications and Corporate Affairs)

Remuneration/Noms committee minutes available – template to be devised to

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(for NEDs) or the Board of Directors (for EDs). ensure future full compliance with FPPT

Review of Job Descriptions for all Executive Directors and Non-Executive Directors

Ann Stringer (Human Resources) Jim Mackey (Chief Executive) Brian Flood (Chairman)

Gaps have been identified and job descriptions have been distributed for updating.

NED/Executive Appraisal Frameworks Ann Stringer (Human Resources) Jim Mackey (Chief Executive) Brian Flood (Chairman)

Development of the new NED Appraisal Framework (including the value based NED competence framework) which has been developed in draft format awaiting the appointment of a new chairman to lead the ratification and future implementation.

NED competence framework Ann Stringer (Human Resources) Jim Mackey (Chief Executive) Brian Flood (Chairman)

As above

Notes of ED appraisals Ann Stringer (Human Resources) Jim Mackey (Chief Executive) Brian Flood (Chairman)

Audit completed

Initial self-declaration of fitness including explanation of past conduct/character issues (where appropriate)

Ann Stringer (Human Resources) All returned and completed

Ongoing self-declaration of fitness including explanation of past conduct/character issues

Ann Stringer (Human Resources) Embedded within appraisal

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(where appropriate) within Executive/Non-Executive Appraisal documentation

documentation and to be done annually

Review of all DBS checks for existing post holders

Ann Stringer (Human Resources) Audit complete to review all DBS checks for existing post holders - where required in line with the regulations updated DBS checks have been completed or are in process. Some additional checks have been undertaken not as a requirement of the regulations but in order to support good governance.

Review of contracts of employment to include termination in the event of non-compliance and incorporation of maintenance of fitness to practice as a contractual requirement (service agreements or equivalent for NEDs).

Ann Stringer (Human Resources) Letter of amendment issued to all Executive Directors, Directors, Non-Executive Directors, Deputy Directors and Business Unit Directors.

Policy Development

To develop a Trust Disclosure and Barring Service (DBS) policy in line with best practice as outlined by the Disclosure and Barring Service and NHS Employers.

Ann Stringer (Human Resources) Policy scheduled for approval at Assurance Committee 11.11.15

enc 9 human resources/organisational development report - northumbria healthcare nhs ... ·...

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