standard operating procedure (sop) for the role of mental

This document is uncontrolled once printed. Please refer to the Trust intranet for the current version. SOP-MHMOC review Oct. 21

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Standard Operating Procedure (SOP) for the role of Mental Health

Manager-on-call


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Table of Contents Standard Operating Procedure (SOP) for the role of Mental Health Manager-on-call .......................... 1

Why we need this Standard Operating Procedure ............................................................................. 3

What the Standard Operating Procedure is trying to do .................................................................... 3

Which stakeholders have been involved in the creation of this Procedure ....................................... 3

Any required definitions/explanations ............................................................................................... 4

Key duties ............................................................................................................................................ 4

Standard Operating Procedure detail ................................................................................................. 7

Key duties of the Manager-on-call .................................................................................................. 7

Communicating with External Agencies ......................................................................................... 8

Who is eligible for Manager-on-call ................................................................................................ 8

Manager-on-call Rota ..................................................................................................................... 8

Rota Administration ........................................................................................................................ 9

Sickness and absence ...................................................................................................................... 9

Remuneration for staff undertaking Manager-on-call ................................................................... 9

Training requirements associated with this Procedure .................................................................... 10

For further information ..................................................................................................................... 10

Equality considerations ..................................................................................................................... 10

Document control details ................................................................................................................. 11


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Why we need this Standard Operating Procedure

Northamptonshire Healthcare NHS Foundation Trust (The Trust) is committed to the availability of

Senior Management support to staff within its 24 hour services, outside of normal working hours.

The operation of 24 hour services can sometimes require the support of Senior Management or

Directors, for reporting/authorisation purposes and particularly when incidents occur which may be

outside the capability or authority of staff on duty.

What the Standard Operating Procedure is trying to do

The provision within the policy covers 365 days per year.

The purpose of this policy is to provide guidance to both Senior Managers and those staff requiring

the support of Managers or Directors outside of working hours, on actions to take when undertaking

on-call, or contacting the Manager or Director on-call

The objectives of the policy are to:

Provide guidance for persons undertaking on-call on what the expectations are whilst they are on-

call

Provide guidance to staff requiring support from Senior Management or Directors out of hours as to

the process to contact Senior Management/Directors, and what constitutes a reason to contact

Senior Management/Directors out of hours

Provides guidance for staff requiring support from Senior Management/Directors out of hours as to

action that should have been undertaken prior to contacting senior management out of hours

Provide a framework for recording all activities call-outs

Provide an outline of the expectations upon managers and clinical leaders undertaking on-call duties

Which stakeholders have been involved in the creation of this Procedure

Adult Mental Health, Learning Disability and Specialty Services Directorate Management Team


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Any required definitions/explanations

Out of Hours - These are the hours in which the on-call service will operate and refers to those

hours, which are outside of normal working hours (9.00 a.m. – 17.00 Monday to Friday, except Bank

Holidays).

Therefore, the term out of hours covers weekends and 17.00 hours – 9.00 hours Monday – Friday,

plus public holidays when normal working hours are suspended and weekend on-call arrangements

apply

On-Call - When a member of staff is required to be contactable and available in the event of Senior

Management/Director support being needed outside of normal working hours. Note: On-call

managers continue to work their normal working hours the following day

On-Duty - When staff members, of any position, work within their paid/contracted hours, usually

over a 24-hour period which incorporates rest breaks

Operational Manager and Clinical Lead- For the purposes of this policy only is the defined group of

staff undertaking the role of Manager-on-call, who are not Out of Hours Managers.

Notifying Person – The nominated clinical team leader for both hospital sites, and the person in

charge for a community based service during the out of hour’s period

Key duties

Director-on-call

The Director-on-call is available to provide senior board level representation for the Trust outside of

normal working hours. This can involve

Providing support to the Manager-on-call and support to staff on duty within 24 hour services.

Providing support to the Manager-on-call in situations where a greater degree of authority is

required or where a situation is beyond the capability of the individual on-call

Attending the site of any serious untoward incidents in support of the Manager-on-call and staff

directly involved in the incident duty

Providing a link to the out of hours services provided by local services


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Providing a link to the Health Executive East Midlands out of hours provision via the regional ‘first

response’ arrangements, including access to legal advice

Acting as a board level representative of the Trust in situations where media contact is required or

likely, outside of normal working hours In line with the Major Incident Policy to act as dictated by the

situation, taking strategic oversight of the next steps in the Trust’s incident management.

For the purposes of this policy, the Manager-on-call is the only person from the Directorate who will

contact the Director-on-call out of hours.

Out of Hours Managers

Within the Mental Health, Learning Disability and Specialty Services Directorate there are 4 Out of

Hours Managers. These 4 managers work predominantly night shifts, with some weekends and are

based at either St Mary’s Hospital or Berrywood Hospital.

The role of the Out of Hours Manager is to provide managerial support to all clinical services within

the directorate at night. They are based within the hospitals because this is where the majority of

clinical services out of hours are provided. The role of the Out of Hours Managers is a mobile one

and requires the post holders to travel between sites when necessary. They are supernumary and

therefore not attached any ward’s staffing levels. They are expected however, in the absence of a

nominated CTL (see below) to fulfil their duties for matters requiring escalation and site

management.

Rotas and annual leave between the 4 Out of Hours managers is arranged to ensure that at least one

is on duty every night of the year. The hours of operation mirror the night shift pattern that both

hospitals operate. These are 2015hrs until 0800hrs.

As part of their duties, Out of Hours Managers take over the role of the On-Call Manager when on

duty.

Nominated Clinical Team Leader (NCTL)

Each hospital site has a nominated Clinical Team Leader out of hours. The role of the NCTL is to

cover the management duties of the hospital in the absence of Ward managers and Service

Managers. Although each ward has a designated nurse in charge, a CTL is nominated each shift to

cover hospital wide issues such as fire response, emergency procedures and staffing matters. They

are the filter for all wards access to duty doctor out of hours. The nominated CTL is the first point of

escalation for the wards at each hospital and therefore the notifying person to the on call manager

from the hospitals. Individual wards are not to contact the Manager-on-call directly.

Bed Managers

Within office hours each hospital site has an identified Bed Manager and Bed Liaison / Co-ordinator

for the management of beds within the adult inpatient areas. At the end of each weekday, each

hospital site provides a bed report which amongst other things advises of the overall bed state,


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including available beds, out of area beds in use and the number of referrals awaiting admission.

Using a rag rating system, any leave beds are rated according to whether they can be used or not.

Out of hours, individual wards manage their own beds with the nurse in charge of each of the acute

wards assuming the role of Bed Manager. Discussions around sourcing an out of area bed out of

hours should always consider the information provided in the daily bed report. Please see Procedure

for Acute Bed Management for full details

List of Services for on call and escalation

Location Service Name

Berrywood Hospital Adult Mental Health Harbour Ward

Bay Ward

Cove Ward

Marina Psychiatric Intensive Care Unit (PICU)

Forensic and Rehab Wheatfield Low Secure Unit

Meadowbank Unit

Older People Brookview Unit

Riverside Unit

Child and Adolescent The Burrows

The Sett

St Mary’s Hospital Adult Mental Health Kingfisher Ward

Sandpiper Ward

Avocet Ward

Shearwater Psychiatric Intensive Care Unit (PICU)

Older People Spinney

Orchard

Community Mental Health

Urgent Care and Assessment North and South

Planned Care and Recovery North and South

N-STEP

Community Forensic Team

Crisis Pathway

The Warren (Crisis House)

Crisis Cafés – County wide

NGH and KGH Acute Liaison Mental Health Service North and South

Police Liaison Op Alloy, Liaison and Diversion, Police Custody

Learning Disability Services

Community Team for People with Learning Disabilities (CTLPD)

Intensive Support Team

1 Willow Close

Opportunities for You


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Standard Operating Procedure detail

It is expected that clinical services will escalate matters to the Manager-on-call after firstly

attempting to resolve the issues locally. Notifying persons should expect to be asked by the

Manager-on-call what actions have been taken, the reasons for escalation and should expect to be

asked what action would normally be taken in these circumstances. Managers on Call are not

expected to have an in-depth clinical or operational knowledge of every service and therefore are

not able to provide clinical solutions in most cases. The role of the Manager-on-call is to support

clinical services by facilitating solutions using the expertise and experience of those within the

affected service.

Key duties of the Manager-on-call

Be the first point of contact for teams/services operating outside normal working hours and needing

to report in accordance with their own operating procedures and Trust Policy

Give verbal, over the phone support and advice, to notifying persons when they are dealing with

incidents outside of their normal capability.

Provide authorisation in line with Trust/Local Policy, e.g. where the expenditure exceeds the

authority of the senior staff on duty. The Manager-on-call is required to authorise the use of agency

staff out of hours.

When it has been established that an out of area bed is required, seek authorisation from the

Director-on-call in line with Trust policy.

Receive verbal ‘over the phone’ reports in line with Trust Policy, e.g. serious incidents, sudden,

unexpected death, business continuity planning, i.e. disruption to services in the event of fire, flood,

disasters, bomb threats, etc.

Attend incident scenes, in the event of a serious untoward incidents or major disruption, as per the

Trust’s Major Incident Plan.

Escalate reports of exceptional matters to the Director on-call where appropriate in line with this

policy.

Provide any follow-up details of the out of hour’s incident to the relevant service manager at the

first available opportunity during normal working hours

Participate in a teleconference handover every Monday and Friday morning, in order to share

information/ raise any issues or matters relating to out-of-hours delivery of services

Record all calls and the action taken within their own Emergency on-call log book in order that

information can be collated/monitored and shared should it be needed for evidential value or as

part of an investigation


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Communicating with External Agencies

The Manager-on-call will frequently receive calls from external agencies such as the police,

Northampton and Kettering General Hospitals. These calls will usually arise when there are

pressures within these agencies and the trust is seen as part of the reason for them or the solution

to alleviate them

In all cases where an external agency contacts the Manager-on-call, it is important that before giving

any assurances or agreeing any actions, contact with the relevant trust service within that area is

made by using the list above to gain a full understanding of the issues involved. In some cases

situations may have already been resolved. In those cases where a resolution is still being sought,

consideration must be given to the wider pressure across the whole system. The safety of the

patient(s) is the priority and their whereabouts and the impact of interim plans to alleviate pressure

elsewhere must always be considered first as part of any decision. Where required support is always

available from the Director on call and therefore managers on call should not feel they are dealing

with these situations alone.

Who is eligible for Manager-on-call

The Criteria for inclusion on the Manager-on-call rota for directorate is as follows:

All operational managers for clinical services and teams

All Band 7 clinical leadership nursing posts

Out of Hours Managers

Manager-on-call Rota

Each week is split into 2 periods of on-call, with an on call manager assigned to one period. These

are Monday 5pm until Friday at 9am and Friday 5pm until Monday at 9am.

Each day on-call is split into 2 sessions. Monday to Friday, the first session starts at 1700hrs until

2030hrs. The second session runs from 2030hrs until 0800hrs.

At Weekends and Bank Holidays the first session starts at 0800hrs until 2030hrs. The second session

commences 2030hrs until 0800hrs.

Every effort is made to ensure that the second session of on-call throughout the duration of the rota

is covered by one of the Out of Hours Managers. Annual leave, Training and other leave is co-

ordinated between the two hospitals to ensure one of the 4 Out of Hours Managers is always

rostered to work.

The required level of cover for the Manager-on-call rota at any point in time is 1 person. Operational

Managers and Clinical leaders described in the previous section who are on call for the first session

are only required to cover the second session in the event of one of the Out of Hours Managers

being absent. On the rota, the cover arrangements for the absence of the OOH Manager are

described as 2nd Night Manager. The 2nd night manager is not on call if the night manager reports for

duty.


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However, the 2nd night manager identified through the rota is required to remain contactable by

phone, solely for the purposes of covering the remainder of the duty should the Out of Hours

Manager become unwell during their shift.

Rota Administration

Each rota is for one month, is completed 6 weeks in advance by one of the Directorate Management

Administrators. In developing and producing the rota, availability of on call managers will be sought

and the rota arranged accordingly to avoid clashes with planned annual leave etc.

Once the rota has been finalised, if managers are then unavailable for their allocated period, they

are responsible for ensuring their own cover arrangements with colleagues and informing the

directorate administrator of the changes accordingly.

Part time staff are required to complete a full on call. To facilitate this, part time staff are required to

organise a buddy where both on-call periods are shared between both parties. This will ensure part

time staff are not on-call during the days they are not at work.

Sickness and absence

Sickness and absence notification during or prior to any on-call period must be co-ordinated

effectively. Managers undertaking on-call are not expected to cover on call duties if not fit for work,

therefore in the event of a manager not reporting for their normal duty, as per the sickness policy

they must advise their manager. The manager will then organise cover for the on-call period from

within their own area. In all cases, Berrywood Hospital Reception must be informed of any changes

to the rota.

The Out of Hours Managers must ensure in the event of becoming unwell prior to their shift

commencing this is reported to their own manager as per the trusts sickness policy. If this is out of

office hours, they must also inform the manager on-call through Berrywood Reception and advise

them that they will be required to cover the night shift. Berrywood Reception once informed will

adjust their rotas accordingly.

In the event of the OOH Manager becoming unwell during their shift, they must contact the 2nd night

manager and advise them of this. In the event of the OOH Manager needing to leave their period of

duty, the 2nd night manager is required to assume the role of Manager-on-call and respond to calls

accordingly.

Remuneration for staff undertaking Manager-on-call

Managers are not paid for undertaking a period of on-call. However, Managers-on-call will receive

time off in lieu for dealing with on-call matters by telephone. This will be accrued in 15 minute

blocks for both telephone calls and any work completed by remote working in relation to these calls.

This time off in lieu must be arranged through the staff members Head of Service on the next

working day.

Managers-on-call who are required to attend work premises as part of on-call duties will be paid

both travel expenses and for the time they attended, including travel time.


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Training requirements associated with this Procedure

All on call staff will have read and adhere to the On Call Policy.

Staff will made aware of the policy through a variety of means such as operational management

team meetings, directorate management team meetings and through the trust intranet.

New staff undertaking the Manager-on-call for the first time will do so with the support of a buddy

from their own area appointed by their manager.

For further information

Please speak with

Gail Everett, Directorate Management Administrator, Adult Mental Health Services South

Andres Patino, Head of Adult Mental Health Services South

Anne Rackham, Assistant Director, Mental Health, Learning Disability and Speciality Services

Adam Smith, Head of Crisis Pathway.

Equality considerations

The Trust has a duty under the Equality Act and the Public Sector Equality Duty to assess the impact

of Policy changes for different groups within the community. In particular, the Trust is required to

assess the impact (both positive and negative) for a number of ‘protected characteristics’ including:

Age;

Disability;

Gender reassignment;

Marriage and civil partnership;

Race;

Religion or belief;

Sexual orientation;

Sex;

Pregnancy and maternity; and

Other excluded groups and/or those with multiple and social deprivation (for example

carers, transient communities, ex-offenders, asylum seekers, sex-workers and homeless

people).


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The author has considered the impact on these groups of the adoption of this Procedure. The

Manager-on-call rota gives flexibility to ensure fairness to protected groups and others with those

affected having the opportunity to swap duties to accommodate those needs. Those undertaking the

role who are pregnant should discuss their needs with their manager. Symptoms relating to

pregnancy may affect a person’s ability to complete a period of on call and if this is determined,

using the trusts maternity policy and risk assessment, arrangements can be made to remove the

pregnant staff member from the rota until they return to work following their maternity period.

(a) Line Managers should ensure that staff returning from maternity or paternity leave, are given

time to update themselves on any changes made to the policy.

(b) Equality Considerations - Should the reader of this policy or any other group believe they are

disadvantaged by anything contained in this policy, please contact the Equality & Inclusion Manager,

who will then actively respond to the enquiry.

Document control details

Author: Andres Patino

Approved by and date: DMT 11.10.2018

Responsible committee: DMT

Any other linked Policies: HRp033Maternity, Paternity and Adoption Leave Protocol CLPr018 Mental Health Acute Outflows from NHFT Procedure Procedure for Mental Health Acute Bed Management CRM002 Incident Policy (including near miss and serious incidents) CRM010 Reporting and management of serious incidents policy

Policy number: SOP-MHMOC

Version control: 1

Version No.

Date Ratified/ Amended

Date of Implementation

Next Review Date

Reason for Change (eg. full rewrite,

amendment to reflect new legislation, updated flowchart, minor amendments, etc.)

1 11.10.2018 18.12.2018 11.10.2021 New


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standard operating procedure (sop) for the role of mental

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