ITEM 17 Reporting Duties Health and Care (Staffing) (Scotland) Act 2019
North Lanarkshire Council · 27 March 2024
Back to Health and Social Care Integration Joint Board — 27 March 2024 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 17 SUBJECT: Reporting duties for local authorities and integration under Health and Care (Staffing) (Scotland) Act 2019 TO: Integration Joint Board Committee Lead Officer for Report: Ross McGuffie NL HSCP Chief Officer Author(s) of Report Stacey Anderson Support Services Project Manager DATE: 27 March 2023 1. PURPOSE OF REPORT This paper is coming to the IJB for: For approval ☐ For endorsement ☐ To note ☒ 2. ROUTE TO THE BOARD This paper has been: Prepared By: ☒ Reviewed By: ☐ Endorsed By: ☐ Stacey Anderson, Support Services Project Manager
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2 3. RECOMMENDATIONS To note the content of the report and be advised of the reporting duties for local authorities and integration authorities under Health and Care (Staffing) (Scotland) Act 2019. 4. VARIATIONS TO DIRECTIONS? 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Reporting duties for local authorities and integration authorities under Health and Care (Staffing) (Scotland) Act 2019 applies to the provision of adult services, children and young people’s services and early learning and childcare services. 5.2 Reporting duties apply to all sectors where local authorities and integration authorities plan or secure service from another person under contract, agreement, or other arrangements. This includes funded providers. 5.3 Part one, section 3 of the Act makes provision for local authorities and integration authorities to publish annual information on the steps they have taken to comply with the requirements when planning or securing a care service. 5.4 The Scottish Government HCSSA Implementation Team intend to liaise with the ministerial teams who have responsibility for children, young people, and justice services regarding these new duties. 6. CONCLUSIONS 6.1 To support reporting, the Scottish Government have devised a template which consists of two questions. Ministers may review or revise these questions after enactment on 1 April 2024. You will find these below: 1) Please detail the steps you have taken as an organisation to comply with section 3(2) of the Health and Care (Staffing) (Scotland) Act 2019 2) Please detail any ongoing risks that may affect your ability to comply with the duty set out in section 3(2). Yes ☐ No ☒ N/A ☐
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3 6.2 The attached HCSA Q2 Reporting Template details the most recent update report to Scottish Government from a North Lanarkshire Health and Social Care Partnership Nursing perspective. This template and submission has been used as part of a pilot to test the quarterly return report prior to enactment. 6.3 Once the official template and report guidance has been issued, a further report will be shared with the IJB. 7. IMPLICATIONS 7.1 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer ☐ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☐ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☐ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☐ Health and Social Care Services contribute to reducing health inequalities ☐ People who use Health and Social Care Services are safe from harm ☒ People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☒ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☒ 7.2 ASSOCIATED MEASURE(S) 7.3 FINANCIAL This paper has been reviewed by Finance: Yes ☐ No ☐ N/A ☒
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4 7.4 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner Choose an item. 7.5 ENGAGEMENT & PARTICPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details regarding the engagement and participation that was undertaken. Objectives Further Details ☐ Involve stakeholders in the development work aimed at achieving the national outcomes ☐ Provide stakeholders with information on how to get involved ☐ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs ☐ Measure how well we involve community stakeholders in the planning, design and delivery of our services ☐ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery ☐ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings ☐ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff ☐ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership
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5 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: EQIA added to website: 8. BACKGROUND PAPERS Health and Care (Staffing) (Scotland) Act 2019 (legislation.gov.uk) 9. APPENDICES Please include a glossary of terms if not already included. 9.1 Appendix 1- HCSA – Q2 Reporting Template CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following; Ross McGuffie Ross.McGuffie@lanarkshire.scot.nhs.uk Yes ☐ No ☐ N/A ☒ Yes / Date added ☐ No ☐ N/A ☒
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6 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 2 Report Title 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction 10 Performance Management / Governance arrangements 11 Date direction will be reviewed
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7 Appendix 1 1 2 3 4 Summary report Please answer the questions below, to provide an overall assessment of how the organisation has carried out its duties under section 2 of the 2019 Act, and sections 12IA, 12IC, 12ID, 12IE, 12IF, 12IH, 12II, 12IJ and 12IL of the 1978 Act (inserted by section 4 of the 2019 Act). Please advise how the information provided in this report has been used or will be used to inform workforce plans. Please summarise any key achievements and outcomes as a consequence of carrying out the duties and requirements in the Act. For the quarterly returns this will be key acheivements and outcomes in preparation for compliance. Please also detail the objectives for the next quarter. Please summarise any key learning and risks identified as a consequence of carrying out the duties and requirements in the Act. For the quarterly returns this will be key learning and risks identified in preparation for compliance. Reasonable Assurance Please indicate the overall level of assurance of the organisation's compliance with the Act, reflecting the report submitted. For the quarterly returns this will be overall level of assurance of the organisation's preparedness for enactment in April 2024. The information contained in this workplan has been used to identify outstanding work to hep us prepare for implementation of the act and we now have a action plan which we are monitoring closley. Training has been undertaken with all senior leaders in the organisation to senior charge nurse/ team leader level on safe staffing legislation and also safe rostering. Staff feedback from both these sessions have been extremely positive. Challenges in running tools within integrated tools where full staffing and skill mix is not included. It is not clear how useful this information will be in workforce planning. If staff don’t see the direct link there is concern that participation in tool runs will dip.
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8 1 Guiding principles for health and care staffing 2 Guiding principles etc. in health and care staffing and planning Guidance chapter link Section Status 12IA(1) Green 12IA(2)(a) Green 12IA(2)(b) Green 12IA(2)(c) Green 12IA(2)(d) Green 12IA(2)(e) Green 2(1) Green N/A Green These are steps taken to comply with 12IA in general. Examples could include information about workforce planning, national and international recruitment, retention, retire and return, service redesign, innovation, staff wellbeing, policies around supplementary staffing, This should include, but not be limited to data in relation to patient safety and quality of care measures and outcomes, patient feedback and adverse event reporting. These systems and processes include having regard to the local context in which it is being provided These systems and processes include having regard to the number of patients being provided it These systems and processes include having regard to the nature of the particular kind of health care provision 12IA Duty to ensure appropriate staffing RAG status Item Clearly defined systems and processes are in place, and utilised, in all NHS functions and professional groups to ensure that at all times suitably qualified and competent individuals, from such a range of professional disciplines as necessary (see guidance for details of professional disciplines included within the Act) are working in such numbers as are appropriate for the health, wellbeing and safety of patients; the provision of safe and high- quality health care; and in so far as it affects either of those matters, the wellbeing of staff. These systems and processes include having regard to the guiding principles when carrying out the duty imposed by section 12IA Please provide information on how these systems and processes, and their application, have improved outcomes for service users Please provide information on the steps taken to comply with section 12IA. Comment There is a clearly defined mechanism for monitoring compliance with this duty and escalation of non-compliance (when this cannot be adequately met) These systems and processes include having regard to appropriate clinical advice Processes are in place to provide assurance that appropriate staffing is in place and that guiding principles are taken into account when decisions relating to staffing requirements are made. Processes are in place to provide assurance that where risk exists that appropriate mitigation is in place. Processes are in place to enable staff to comment on staffing levels and for staff to be informed of decisions relating to staffing. Processes are in place to provide assurance that where a Health Board or Integration Authority are commissioning Health Services from another provider that the provider complies with the general duty and principles of this Act and to record any challenges faced. The PRAG tool has provided evidence of high risk areas that has allowed us to focus recruitemnt drives and also to support use of supplementary staffing due to the risk. This has resulted in safer enviroments for our patients and staff These systems and processes include having regard to the needs of patients being provided it
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9 Areas of success, achievement or learning Areas of escalation, challenges or risks Level of risk (RAG) This is the residual level of risk, taking into account the actions taken. Level of Assurance: Please indicate level of assurance provided Local Real Time Staffing Assessment Tool developed in line with national resources and completed at start of each shift on a daily basis. Trend data Risk Register PRAG reports Action Plans Clinical and Staff Governance Groups Team Meetings 1:1 in place for all staff to provide opportunity for feedback and discussion. Trend data, iMatter Surveys, Action Plans Governance Groups Minutes Workload Tool reports This should include details of the NHS function / professional group etc. that the area of success, achievement or learning relates to. This should describe the situation: what is the success, achievement or learning. For example, application of eRostering has allowed senior personnel to be able to see staffing in real-time across all areas, allowing staff to be reallocated as required to reduce level or risk. This should describe how the success, achievement or learning could be used in the future. Continue the roll out of eRostering across the organisation, using learning from areas that have already implemented. Workforce tools including PJ and workforce reviews carried out annually which will take congnisance of guiding principles and duties within the legislation. Reporting Template developed in line with CSM. Dashboards developed locally to provide current and trend workforce data. Staff and Patient Expeience Survey, Complaints, Imatter, Datix, EIC Dashboard Reporting template developed in line with the Common Staffing Method to complete local context/triangulation process for all worklaod tool results/outcomes. These will be presented via Clinical and Staff Governance Groups. SG Progress Reports, Rosters, Workforce Plans, AOP. orforce tools/PRAG by Senior Nurses/Service Managers and associated actions. Leadership walkrounds Reasonable Assurance Full engagement and completion of PRAG over 7 day period. Real Time Staffing Assessment tool. Post mitigation risks must be completed at all times. Details This should include details of the NHS function / professional group etc. that the area of escalation, challenge or risk relates to. This should describe the situation: what is the challenge or risk identified? For example, there may be difficulty with recruiting a particular staff speciality or in a remote / rural location. Attendance and engagement at Workforce Governance Groups, Safety Huddles, Team Meetings.Sharing of information and feedback to and from teams. Understanding and application of Workload Tools Reportign/Review, PRAG Daily Safe Staffing Assessment Tool Limited staff engagement around staffing levels and associated decisions related to staffing Area of escalation / challenge / risk Integrated working groups - no workload tools or real time staffing assessments in place currently. Poor data quality dependent on staff engagament in prep/planning/housekeeping/training and data capture. Specialty Specific Workload and Workforce Planning Tools do not exist for some clincial areas, especially those with integrated services - Scoping excercise to be completed for these areas re PJ only Tool. Availabilty of workforce is a national challenge Tool is not completed or not completed accurately. Staff understanding of tool and how to use in practice Declaration: The relevant organisation has systems and processes in place to meet the requirements of this duty, and has carried out this duty through the presence and use of appropriate systems and processes as detailed above. Action This should describe what actions have been / are being / will be taken to address the situation. For example, if there is difficulty in recruiting in a particular speciality or remote / rural location, the relevant organisation may have investigated retire and return schemes or upskilling and career development for existing staff. It may also have looked at how the service could be redesigned. Apply local context where appropriate. Develop worklaod tools nationally that are fit for purpose. Oversight Group will monitor risks re preparedness and complaince with legislation. Review absence management processes and return to work support. Review of blueprints and funded establishment using workload and workforce planning tool outcomes/triangulation and RTS resources as evidence. Encourage engagement and completion of Real Time Staffing Assessments daily especially post mitigation. Review risk registers. Develop national annual risk assessment process for reporting. Please provide details of areas of escalation where the relevant organisation has been unable to achieve or maintain compliance or any challenges or risks associated with carrying out the requirements, and the actions in place to address these. Please provide details of areas of success, achievement or learning associated with carrying out the requirements. Area of success / achievement / learning Details Further action
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10 Guidance chapter link Section Status 12IC(1) Yellow 12IC(2)(a) Green 12IC(2)(b) Green 12IC(2)(c) Yellow 12IC(2)(d) Green 12IC(2)(e) Yellow 12IC(2)(f) Yellow 12IC(2)(g) Yellow N/A Green 12IC Duty to have real-time staffing assessment in place RAG status Item These systems and processes include means for encouraging and enabling all staff to use the systems and processes available for identifying and notifying risk to the individual with lead professional responsibility. These systems and processes include the means to provide training to relevant individuals with lead professional responsibility on how to implement the arrangements in place to comply with this duty. Clearly defined systems and processes are in place, and utilised, for the real-time assessment of compliance with the duty to ensure appropriate staffing, in all NHS functions and professional groups. These systems and processes include means for ensuring that individuals with lead professional responsibility receive adequate time and resources to implement those systems and processes. There is a clearly defined mechanism for monitoring compliance with this duty and escalation of non-compliance (when this cannot be adequately met) These systems and processes include the means for any member of staff to identify any risk caused by staffing levels to the health, well-being and safety of patients; the provision of safe and high-quality health care; or, in so far it affects either of those matters, the wellbeing of staff. These systems and processes include the means for the initial notificaiton / reporting of that risk to the relevant individual with lead professional responsibility. These systems and processes include the means for mitigation of risk, so far as possible, by the relevant individual with lead professional responsibility, and for that individual to seek, and have regard to, appropriate clinical advice as necessary. These systems and processes include means for raising awareness among all staff of the methods for identifying risk, reporting to the individual with lead professional responsibility , mitigation, and seeking and having regard to clinical advice. Comment PRAG tool is available but still issues with staff completion compliance Mitigation of risk is taking place but not always recirded as well as could be ongoing staff training with the tools ongoing staff training with the tools system pressures are impacting on lead nurses ability to monitor as closely as we would like and to keep records up to date 24/7 discussed at every nursing workforce meeting and compliance monitored. Areas for improvement identified
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11 Areas of success, achievement or learning Areas of escalation, challenges or risks Level of risk (RAG) This is the residual level of risk, taking into account the actions taken. Level of Assurance: Please indicate level of assurance provided Real Time SResources beign carried out daily withn most clinical settings. Allows for overview of risks by ward/team/division/locality/site etc. Trend data, risk registers, patient/staff experience surveys, EIC quality measures. Action Plans Clinical and Staff Governance Groups Please provide details of areas of success, achievement or learning associated with carrying out the requirements. Area of success / achievement / learning Details Further action This should include details of the NHS function / professional group etc. that the area of success, achievement or learning relates to. This should describe the situation: what is the success, achievement or learning. For example, areas that have implemented and are using SafeCare are finding it easy to be able to record risks that are identified and the mitigation measures implemented and clinical advice received. Reports extracted from the system are demonstrating an auditable trail of decision-making. This should describe how the success, achievement or learning could be used in the future. This success is being used to demonstrate to other areas the benefits of using SafeCare and supporting its implementation. Please provide details of areas of escalation where the relevant organisation has been unable to achieve or maintain compliance or any challenges or risks associated with carrying out the requirements, and the actions in place to address these. This should describe the situation: what is the challenge or risk identified? For example, there may be difficulty with encouraging and enabling certain professional groups to use the systems and processes. Data is not completed or updated on a daily basis, especially post mitigation. This should include details of the NHS function / professional group etc. that the area of escalation, challenge or risk relates to. Accurate and consistent completion of PRAG Daily Safe Staffing Assessment Tool currently hosted on excel platform and PJ used for metric to calculate staffing levels in relation to patient dependency. Reasonable Assurance Declaration: The relevant organisation has systems and processes in place to meet the requirements of this duty, and has carried out this duty through the presence and use of appropriate systems and processes as detailed above. Area of escalation / Challenge / Risk Details Action This should describe what actions have been / are being / will be taken to address the situation. For example, if there is difficulty in engaging certain professional groups, what measures have been put in place with regard to increasing this such as using professional networks, staff representatives etc. Review of risks an escalation plans enacted as appropriate.
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12 Guidance chapter link Section Status 12ID(1) Yellow 12ID(2)(a) Yellow 12ID(2)(b) Green 12ID(2)(c) Yellow 12ID(2)(d) Yellow 12ID(2)(e) Yellow 12ID(2)(f) Green 12ID(2)(g) Yellow 12ID(2)(h) Yellow 12ID(2)(i) Yellow 12ID(2)(j) Yellow N/A Green Areas of success, achievement or learning There is a clearly defined mechanism for monitoring compliance with this duty and escalation of non-compliance (when this cannot be adequately met) Please provide details of areas of success, achievement or learning associated with carrying out the requirements. These systems and processes include means for ensuring that individuals with lead professional responsibility and other senior decision-makers receive adequate time and resources to implement the arrangements. These systems and processes include the means to provide training to relevant individuals with lead professional responsibility and other senior decision-makers on how to implement the arrangements in place to comply with this duty. These systems and processes include means for raising awareness amongst all staff of the arrangements stated in (a) to (g) above. 12ID Duty to have risk escalation process in place Item Clearly defined systems and processes are in place, and utilised, in all NHS functions and professional groups, for the escalation of any risk identified through the real-time staffing assessment processes which has not been possible to mitigate. These systems and processes include the means for the lead with professional responsibility to report the risk to a more senior decision-maker. These systems and processes include the means for that senior decision-maker to seek, and have regard to, appropriate clinical advice, as necessary, when reaching a decision on a risk, including on how to mitigate it. These systems and processes include the means for the onward reporting of a risk to a more senior decision-maker in turn, and for that decision-maker to seek, and have regard to, appropriate clinical advice as necessary, when reaching a decision on a risk, including on how to mitigate it. These systems and processes include means for this onward reporting in (c) to escalate further, as necessary, in order to reach a final decision on a risk, including, as appropriate, reporting to members of the relevant organisation. These systems and processes include means for notification of every decision made following the initial report, and the reasons for that decision, to anyone involved in identifying the risk, attempting to mitigate the risk, escalation of the risk and providing clinical advice. These systems and processes include means for anyone involved in identifying the risk, attempting to mitigate the risk, escalation of the risk and providing clinical advice to record any disagreement with any decision made following the initial identification of a risk. These systems and processes include means for anyone involved in identifying the risk, attempting to mitigate the risk, escalation of the risk and providing clinical advice to request a review of the final decision made on an identified risk (except where that decision is made by members of the relevant organisation). compliance monitored via PRAG Comment documentation of mitigating actions being impacted by system pressures needs built into escalation SOP Escalation SOP in development. Local agreement that any risks that cant be mitigated to Red to be escalated to associate nurse director and any purple risks to be escalated to nurse director. Escalation is not happening consistently as above as above as above
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13 Areas of escalation, challenges or risks Level of risk (RAG) This is the residual level of risk, taking into account the actions taken. Level of Assurance: Please indicate level of assurance provided Risk Register, Action Plan, Workforce Plan, Legislation requirements Development of board wide NMAHP risk esclation Process/SOP is currentlyunderway Trend data - review of risks before and after mitigation Risk Register, Action Plan, Workforce Plan, Legislation requirements Development of board wide NMAHP risk esclation Process/SOP is currentlyunderway Risk Register, iMatter, Huddles, 1:1 meetings Workload Tool reports, Action Plan, Workforce Plan Further action This should include details of the NHS function / professional group etc. that the area of success, achievement or learning relates to. This should describe the situation: what is the success, achievement or learning. For example, senior decision-makers in paediatric nursing were identified and chain of escalation communicated to all personnel. Individuals are now much better aware of who to contact during any particular shift in the event that a risk needs to be escalated. This should describe how the success, achievement or learning could be used in the future. The procedures for identifying the chain of escalation that were used in paediatric nursing are now be trialled and rolled out across other areas. Evidence of escalation details facilitated within PRAG Daily Safe Staffing Assessment Tool Trend data, Risk Register, Action Plans Action Plans, workforce reports Risk Register stil to be developed incorporating details of further mitigation/actions/feedback etc. Awareness of mitigation and actions Reasonable Assurance Area of escalation / Challenge / Risk Details This should include details of the NHS function / professional group etc. that the area of escalation, challenge or risk relates to. This should describe the situation: what is the challenge or risk identified? For example, there may be difficulty with ensuring relevant individuals involved in reporting, mitigating, escalating or giving clinical advice on a risk are notified of decisions made the reasons for them. Please provide details of areas of escalation where the relevant organisation has been unable to achieve or maintain compliance or any challenges or risks associated with carrying out the requirements, and the actions in place to address these. Area of success / achievement / learning Details Development of board wide NMAHP risk esclation Process/SOP is currentlyunderway Trend data - review of risks before and after mitigation Briefings, Team Meetings, one to ones, Huddles Declaration: The relevant organisation has systems and processes in place to meet the requirements of this duty, and has carried out this duty through the presence and use of appropriate systems and processes as detailed above. Action This should describe what actions have been / are being / will be taken to address the situation. For example, if there is difficulty in notifying relevant individuals about decisions made and the reasons for them, what measures have been put in place to ensure this happens, such as providing training, increasing awareness and auditing to identify root causes. Escalation plans enacted. Staff supported Team Briefs, Workforce Governance Meetings, Escalation plans Action logs, briefing logs Maintance of proportionate risk escalation due to the impact of COVID 19 and continued staffing challenges nationally Risks are not identified or managed. Availabillity of staff to mitigage risk Development of board wide NMAHP risk esclation Process/SOP is currentlyunderway Risks are not identified or managed. Availabillity of staff to mitigage risk Risk Register stil to be developed incorporating details of further mitigation/actions/feedback etc. Decision making around risk is not fully evidenced and understood
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14 12IE Duty to have arrangements to address severe and recurrent risks Guidance chapter link Section Status 12IE(1)(a) Green 12IE(1)(b) Green 12IE(2)(a) Green 12IE(2)(b) Green 12IE(2)(c) Green 12IE(2)(d) Green N/A GreenThere is a clearly defined mechanism for monitoring compliance with this duty and escalation of non-compliance (when this cannot be adequately met) These systems and processes include means for identification of actions to prevent the future materialisation of such risks, so far as possible. Item Clearly defined systems and processes are in place, and utilised, in all NHS functions and professional groups, for the collation of information relating to every risk escalated to such a level as the relevant organisation considers appropriate. Clearly defined systems and processes are in place, and utilised, in all NHS functions and professional groups, to identify and address risks that are considered severe and / or liable to materialise frequently. These systems and processes include the means for recording risks that are considered severe and / or liable to materialise frequently. These systems and processes include the means for reporting of a risk considered severe and / or liable to materialise frequently, as necessary, to a more senior decision-maker, including to members of the relevant organisation as appropriate These systems and processes include means for mitigation of any risk considered severe and / or liable to materialise frequently, so far as possible, along with a requirement to seek and have regard to appropriate clinical advice in carrying out such mitigation. Comment
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15 Areas of success, achievement or learning Areas of escalation, challenges or risks Level of risk (RAG) This is the residual level of risk, taking into account the actions taken. Level of Assurance: Please indicate level of assurance provided Workforce Governance, Dashboard Workforce Tool Run Reports, new staffing models for services, role development, escalation plans Risk Registers Workforce Plans, Annual workforce reports Further action This should include details of the NHS function / professional group etc. that the area of success, achievement or learning relates to. This should describe the situation: what is the success, achievement or learning. For example, a recurrent risk was identified in the capacity of one laboratory, leading to a delay in testing samples and communicating sample results. Following investigation, the process for booking in samples was streamlined and an admin coordinator was appointed. This has improved performance and the lab is now meeting its targets. This should describe how the success, achievement or learning could be used in the future. For example, the organisation is now looking at whether the changes implemented in the one lab could be applied to other labs, to improve performance across the division. Safety Briefs and Workforce meetings to review risks. Datix reports reviewed at Unit Governance Groups Risk Register, Datix Reports, Unit Workforce Reports Workforce Governance Groups, Workforce Action Plans, Dashboard Monitoring process of current risks and issues Monitoring process of current risks and issues Monitoring process, ongoing review of service Staff engagement to complete PRAG tool and complete datix for recurring risks Accurate completion of PRAG tool and risk severity is not clearly identified. Ongoing review of metrics Consitency of approach, availability of staff, recruitment challenges Wider awareness of risk and escalation Consitency of communication of risk and mitigation Move to untested staffing models, accuracy of data/information Substantial Assurance Area of escalation / Challenge / Risk Details This should include details of the NHS function / professional group etc. that the area of escalation, challenge or risk relates to. This should describe the situation: what is the challenge or risk identified? For example, collation of data in a particular NHS function has identified a risk that materialises frequently, however identification of actions to prevent future materialisation has not improved the situation. Please provide details of areas of escalation where the relevant organisation has been unable to achieve or maintain compliance or any challenges or risks associated with carrying out the requirements, and the actions in place to address these. Please provide details of areas of success, achievement or learning associated with carrying out the requirements. Area of success / achievement / learning Details PRAG tool in place and reviewed. Local meetings and Workforce Governance to escalate risks Trend Data, risk register, Datix an Workforce Reports Declaration: The relevant organisation has systems and processes in place to meet the requirements of this duty, and has carried out this duty through the presence and use of appropriate systems and processes as detailed above. Action This should describe what actions have been / are being / will be taken to address the situation. For example, if identification of actions to prevent a frequent risk has not improved the situation, measures to address could have included establishing a working group to investigate and make recommendations, observing practice in the area, interviewing staff, addressing the staff skills mix, allocating additional assistance, redesigning the service etc.
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16 12IF Duty to seek clinical advice on staffing Guidance chapter link Section Status 12IF(1) Green 12IF(2)(a) (i) and (ii) Green 12IF(2)(a) (iii) and (iv) Green 12IF(2)(b) Green 12IF(2)(c) Green 12IF(2)(d) Green 12IF(2)(e) Green 12IF(3) Green N/A GreenThere is a clearly defined mechanism for monitoring compliance with this duty and escalation of non-compliance (when this cannot be adequately met) These systems and processes include the means to raise awareness among individuals with lead clinical professional responsibility for a particular type of health care in how to implement the arrangements in this duty. These systems and processes include means for ensuring that individuals with lead clinical professional responsibility for a particular type of health care receive adequate time and resources to implement the arrangements. These systems and processes include means for the relevant organisation to have regard to the reports received. These systems and processes include the means for individuals with lead clinical professional responsibility for a particular type of health care to report to the members of the relevant organisation on at least a quarterly basis about the extent to which they consider the relevant organisation is complying with the duties in 12IA to 12IF and 12IH to 12IL. These systems and processes include the means for individuals with lead clinical professional responsibility for a particular type of health care to enable and encourage other employees to give views on the operation of section 12IF and to record those views in the reports to the members of the relevant organisation. These systems and processes include the means whereby if a relevant organisation makes a decision which conflicts with clinical advice received, any person who provided clinical advice on the matter is notified of the decision and the reasons for it and this person is able to record any disagreement with the decision made. Item Clearly defined systems and processes are in place, and utilised, in all NHS functions and professional groups, to seek and have regard to appropriate clinical advice in making decisions and putting in place arrangements relating to staffing under sections 12IA to 12IE and 12IH to 12IL and to record and explain decisions which conflict with that advice. These systems and processes include the means whereby if a relevant organisation makes a decision which conflicts with clinical advice received, any risks caused by that decision are identified and mitigated so far as possible. Comment
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17 Areas of success, achievement or learning Areas of escalation, challenges or risks Level of risk (RAG) This is the residual level of risk, taking into account the actions taken. Level of Assurance: Please indicate level of assurance provided Further action This should include details of the NHS function / professional group etc. that the area of success, achievement or learning relates to. This should describe the situation: what is the success, achievement or learning. For example, the views of employees included in the reports prepared by individuals with lead clinical professional responsibility for a particular type of health care identified a potential improvement in working practices in one area. This should describe how the success, achievement or learning could be used in the future. For example, the potential improvement is being trialled in the one area and if successful will be rolled out across other areas in the organisation. Testing of Guidance Chapter was undertaken allowing for understanding of this duty and any gaps in process - swot analysis completed and fedback Substantial Assurance Declaration: The relevant organisation has systems and processes in place to meet the requirements of this duty, and has carried out this duty through the presence and use of appropriate systems and processes as detailed above. Area of escalation / Challenge / Risk Details This should include details of the NHS function / professional group etc. that the area of escalation, challenge or risk relates to. This should describe the situation: what is the challenge or risk identified? For example, in compiling the reports made to the members of the Health Board, there is are good mechanisms in place for the Medical Director to enable and encourage medical employees to give their views, but the mechanisms for seeking the views of other professional groups for which they are responsible, such as pharmacy employees, are not well established. Hence, the views of these employees are not being sought or incorporated into the reports. Please provide details of areas of escalation where the relevant organisation has been unable to achieve or maintain compliance or any challenges or risks associated with carrying out the requirements, and the actions in place to address these. Please provide details of areas of success, achievement or learning associated with carrying out the requirements. Area of success / achievement / learning Details Action This should describe what actions have been / are being / will be taken to address the situation. For example, if the views of all professional groups are not being sought, what measures have been put in place to engage these groups and proactively seek out their opinions.
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18 12IH Duty to ensure adequate time given to clinical leaders Guidance chapter link Section Status 12IH Yellow 12IH Yellow 12IH Green 12IH Green 12IH Green 12IH Yellow N/A GreenThere is a clearly defined mechanism for monitoring compliance with this duty and escalation of non-compliance (when this cannot be adequately met) These systems and processes include the means to consider outputs from activities carried out to meet this duty in order to inform future workforce planning and protect the leadership time required for clinical leaders. Item Clearly defined systems and processes are in place, and utilised, in all NHS functions and professional groups, to ensure that all individuals with lead clinical professional responsibility for a team of staff receive sufficient time and resources to discharge that responsibility and their other professional duties. These systems and processes include the means to identify all roles, and therefore individuals, with lead clinical professional responsibility for a team of staff. These systems and processes include the means to determine what constitutes sufficient time and resources for any particular individual. These systems and processes include time and resources for these individuals to supervise the meeting of the clinical needs of patients in their care; to manage, and support the development of, the staff for whom they are responsible; and to lead the delivery of safe, high-quality and person-centred health care. These systems and processes include the means for ensuring this duty has been reviewed and considered within the context of job descriptions, job planning and work plans, as appropriate. Comment system pressures are impacting on capacity system pressures have resulted in SCN/ TL having to work clinically during protected time Evidence can be limited but work underway to strengthen via clinical supervision and care assurance
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19 Areas of success, achievement or learning Areas of escalation, challenges or risks Level of risk (RAG) This is the residual level of risk, taking into account the actions taken. Level of Assurance: Please indicate level of assurance provided Team Leaders have protected time for leadership Workforce reports to identify trends. imatter Pyschological safety questionnaires. Workforce reports Review compliance of management of LTSand RTW across HSCP Progress of Assurance priorities Staff feedback via imatter, Psychological safety Team Leaders have protected time for leadership. Development sessions for Team Leaders and for teams Staff feedback Psycholgical safety reports Staff engagement Progress of Assurance priorities Staff feedback via imatter, Psychological safety Development session for Team Leaders. Clinical supervision & Assurance framework Staff feedback Psycholgical safety reports Staff engagement Progress of Assurance priorities Staff feedback via imatter, Psychological safety Declaration: The relevant organisation has systems and processes in place to meet the requirements of this duty, and has carried out this duty through the presence and use of appropriate systems and processes as detailed above. Reasonable Assurance Area of escalation / Challenge / Risk Details This should include details of the NHS function / professional group etc. that the area of escalation, challenge or risk relates to. This should describe the situation: what is the challenge or risk identified? For example, the process in place to identify the roles, and therefore indivduals, with lead clinical professional responsibility for a team of staff does not consistently identify who these individulas are, and therefore sufficient time and resources for these individuals to discharge their responsibilities has not been considered. Please provide details of areas of escalation where the relevant organisation has been unable to achieve or maintain compliance or any challenges or risks associated with carrying out the requirements, and the actions in place to address these. Please provide details of areas of success, achievement or learning associated with carrying out the requirements. Area of success / achievement / learning Details Team Leaders have protected time for leadership. Clinical Supervision & Assurance work Workforce reports. Ongoing assurance reports. Staff feedback This should include details of the NHS function / professional group etc. that the area of success, achievement or learning relates to. This should describe the situation: what is the success, achievement or learning. For example, senior physiotherapists and team leaders convened a working group to determine what sufficient time and resources would look like for individuals with lead clinical professional responsibility for a team of staff. The outcome of the project was a determination of time and resources for different team leaders and feedback so far has been positive. Action This should describe what actions have been / are being / will be taken to address the situation. For example, if the process in place to identify the roles, and therefore individuals, does not consistently identify who those indivduals are, what measures have been taken to address this, e.g. working with all staff groups / clinical areas / teams to identify job titles / roles, utilising HR processes and data, utilising eRostering to identify team leaders etc. Further action This should describe how the success, achievement or learning could be used in the future. This has now been extended to other AHP areas and trialled to see applicability.
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20 12II Duty to ensure appropriate staffing: training of staff Guidance chapter link Section Status Comment 12II Green 12II Green 12II Green 12II Green N/A Green Item Clearly defined systems and processes are in place, and utilised, in all NHS functions and professional groups, to ensure that all employees receive such training as considered appropriate and relevant for the purposes set out in section 12IA(1)(a) and (b) and such time and resources as considered adequate to undertake this training. These systems and processes include means to determine the level of training required, and time and resource to support this, for all relevant employees. These systems and processes include the means to deliver the agreed level of training to all relevant employees. These systems and processes include the means to ensure all relevant employees receive both time and resources to undertake the training. There is a clearly defined mechanism for monitoring compliance with this duty and escalation of non-compliance (when this cannot be adequately met)
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21 Areas of success, achievement or learning Areas of escalation, challenges or risks Level of risk (RAG) This is the residual level of risk, taking into account the actions taken. Level of Assurance: Please indicate level of assurance provided Further action This should include details of the NHS function / professional group etc. that the area of success, achievement or learning relates to. This should describe the situation: what is the success, achievement or learning. For example, the psychology division, in conjuction with HR, has just completed a project to promote more accurate capturing of information relating to continued professional development for psychology colleagues. Feedback from employees is that they have found the new system much easier to use and are now recording relevant CPD. This should describe how the success, achievement or learning could be used in the future. AHP colleagues have now expressed interest in the new system and are undertaking a project to see if they could implement something similar. Protected time for compulsory/mandatory training Learnpro Score card to review compliance of training. Pychological safety results , I Matter Progress of Assurance priorities Staff feedback via imatter, Psychological safety Declaration: The relevant organisation has systems and processes in place to meet the requirements of this duty, and has carried out this duty through the presence and use of appropriate systems and processes as detailed above. Substantial Assurance Area of escalation / Challenge / Risk Details Please provide details of areas of success, achievement or learning associated with carrying out the requirements. Area of success / achievement / learning Details Please provide details of areas of escalation where the relevant organisation has been unable to achieve or maintain compliance or any challenges or risks associated with carrying out the requirements, and the actions in place to address these. Action This should include details of the NHS function / professional group etc. that the area of escalation, challenge or risk relates to. This should describe the situation: what is the challenge or risk identified? For example, clearly defined processes and procedures exist for some groups of staff, e.g. nursing and midwifery, but don't exist for other groups of staff, e.g. healthcare scientists. This should describe what actions have been / are being / will be taken to address the situation. For example, if procedures and processes are not in place for healthcare scientists, what measures need to be put in place to ensure this, such as working with HR and healthcare scientist representatives to define an appropriate training programme, assess training needs of employees and plan for required training to be undertaken.
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22 12IJ Duty to follow the common staffing method (*The relevant organisation must only report on the types of health care, location and employees as detailed in section 12IK) Guidance chapter link Section Status 12IJ(1) Yellow 12IJ(2)(a) Green 12IJ(2)(b) Yellow 12IJ(2)(c)(i) Green 12IJ(2)(c)(ii) Green 12IJ(2)(c)(iii) Green 12IJ(2)(c)(iv) Green 12IJ(2)(c)(v) Green 12IJ(2)(c)(vi) Green 12IJ(2)(c)(vii) Green 12IJ(2)(c)(viii) Green 12IJ(2)(c)(ix) Green 12IJ(2)(c)(x) Green 12IJ(2)(c)(xi) Green 12IJ(2)(d) Green 12IJ(2)(e) Green N/A Green These systems and processes include means to decide what changes (if any) are needed to the staffing establishment and the way in which health care is provided as a result of following the common staffing method. These systems and processes include taking into account appropriate clinical advice. These systems and processes include taking into account any assessment by HIS, and any relevant assessment by any other person, of the quality of health care provided. These systems and processes include taking into account experience gained from using the real-time staffing and risk escalation arrangements under 12IC, 12ID and 12IE. These systems and processes include taking into account comments by patients and individuals who have a personal interest in their health care, which relate to the duty imposed by section 12IA. These systems and processes include taking into account comments by employees relating to the duty imposed by section 12IA. These systems and processes include means to identify and take all reasonable steps to mitigate any risks. There is a clearly defined mechanism for monitoring compliance with this duty and escalation of non-compliance (when this cannot be adequately met) These systems and processes include taking into account patient needs. Item Clearly defined systems and processes are in place, and utilised, in all the types of health care, locations and employees listed in section 12IK, to follow the common staffing method no less often than the frequency prescribed in Regulations. These systems and processes include use of the relevant speciality specific staffing level tool and professional judgement tool as prescribed in Regulations, and taking into account results from those tools. These systems and processes include taking into account relevant measures for monitoring and improving the quality of health care which are published as standards and outcomes under section 10H(1) of the 1978 Act by the Scottish Ministers (including any measures developed as part of a national care assurance framework). These systems and processes include taking into account current staffing levels and any vacancies These systems and processes include taking into account the different skills and levels of experience of employees These systems and processes include taking into account the role and professional duties of individuals with lead clinical professional responsibility for the particular type of health care. These systems and processes include taking into account the effect that decisions about staffing and the use of resources taken for the particular type of health care may have on the provision of other types of health care (particularly those to which the common staffing method does not apply). These systems and processes include taking into account the local context in which health care is provided. Comment tools are being run as outlined but quality of completed tools is variable. As tools become more familiar it is hoped that accuracy of completion will improve. Care assurance work has commenced and ongoing. utilise care opinion and patient complaints but no direct involvement
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23 Areas of success, achievement or learning Areas of escalation, challenges or risks Level of risk (RAG) This is the residual level of risk, taking into account the actions taken. Level of Assurance: Please indicate level of assurance provided Testing of Guidance Chapter was undertaken allowing for understanding of this duty and any gaps in process - SWOT analysis completed and fedback Please provide details of areas of success, achievement or learning associated with carrying out the requirements. Area of success / achievement / learning Details Further action This should include details of the NHS function / professional group etc. that the area of success, achievement or learning relates to. This should describe the situation: what is the success, achievement or learning. For example, application of the common staffing method in adult inpatient provision identified some areas where the staffing establishment needed to be changed and some areas with potential for service redesign. These changes are now in progression and will be trialled to monitor the outcomes. This should describe how the success, achievement or learning could be used in the future. For example, following completion of the trials regarding changes in staffing establishment and service redesign, decisions will be taken as the changes made. These could then be used as case studies to inform training for staff about the use of the common staffing method. Area of escalation / Challenge / Risk Details This should include details of the NHS function / professional group etc. that the area of escalation, challenge or risk relates to. This should describe the situation: what is the challenge or risk identified? For example, the common staffing method was followed at the required frequency in all areas except emergency care provision with an explanation of why this was not completed, e.g. lack of knowledge / training of personnel. Please provide details of areas of escalation where the relevant organisation has been unable to achieve or maintain compliance or any challenges or risks associated with carrying out the requirements, and the actions in place to address these. Declaration: The relevant organisation has systems and processes in place to meet the requirements of this duty, and has carried out this duty through the presence and use of appropriate systems and processes as detailed above. Reasonable Assurance Action This should describe what actions have been / are being / will be taken to address the situation. For example, if the common staffing method was not followed in emergency care provision and this was due to lack of knowledge / training, what measures were put in place to address this, e.g. identifying key personnel, provision of training, assistance from experienced personnel in other areas etc.
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24 12IL Training and consultation of staff (*The Health Board and Agency must only report on the types of healthcare, location and employees as detailed in section 12IK) Guidance chapter link Section Status 12IL Green 12IL(a) Green 12IL(b) Green 12IL(c) Green 12IL(d) Green 12IL(e) Green N/A Green These systems and processes include providing information to employees engaged in the types of health care mentioned in section 12IK about its use of the common staffing method, including the results from the staffing level tool and professional judgement tool; the steps taken under 12IJ(2)(b), (c) and (d) and the results of the decisions taken under 12IJ(2)(e). These systems and processes include ensuring that employees who use the common staffing method receive adequate time to use it. Clearly defined systems and processes are in place, and utilised, in all the types of health care, locations and employees listed in section 12IK, for the training and consultation of employees. These systems and processes include means to encourage and support employees to give views on staffing arrangements for the types of health care described in section 12IK. These systems and processes include means for taking into account and using views received to identify best practice and areas for improvement in relation to staffing arrangements. These systems and processes include training employees (in particular those employees of a type mentioned in section 12IK) who use the common staffing method on how to use it. CommentItem There is a clearly defined mechanism for monitoring compliance with this duty and escalation of non-compliance (when this cannot be adequately met)
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25 Areas of success, achievement or learning Areas of escalation, challenges or risks Level of risk (RAG) This is the residual level of risk, taking into account the actions taken. Level of Assurance: Please indicate level of assurance provided Declaration: The relevant organisation has systems and processes in place to meet the requirements of this duty, and has carried out this duty through the presence and use of appropriate systems and processes as detailed above. Substantial Assurance Please provide details of areas of escalation where the relevant organisation has been unable to achieve or maintain compliance or any challenges or risks associated with carrying out the requirements, and the actions in place to address these. Action This should describe what actions have been / are being / will be taken to address the situation. For example, arranging and delivering training, provision of mentoring from experienced personnel, job planning to ensure adequate time is available for designated personnel to follow the common staffing method. This should include details of the NHS function / professional group etc. that the area of escalation, challenge or risk relates to. This should describe the situation: what is the challenge or risk identified? For example, issues were identified with the lack of training and adequate time for personnel in emergency care provision. Area of escalation / Challenge / Risk Details Please provide details of areas of success, achievement or learning associated with carrying out the requirements. Area of success / achievement / learning Details Further action This should include details of the NHS function / professional group etc. that the area of success, achievement or learning relates to. This should describe the situation: what is the success, achievement or learning. For example, key personnel who were very experienced in using the common staffing method were engaged to train and mentor other personnel involved in the process. This should describe how the success, achievement or learning could be used in the future. For example, those key personnel have now decided to meet regularly in a forum to discuss shared learning and to ensure the common staffing method is used consistently across all relevant areas in the organisation. Testing of Guidance Chapter was undertaken allowing for understanding of this duty and any gaps in process - swot analysis completed and fedback
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26 1 Guiding principles for health and care staffing 2 Guiding principles etc. in health and care staffing and planning Guidance chapter link Section Status 2(2) These are steps taken to comply with 2(2) in general. Examples could include information about procurement and commissioning processes, how the guiding principles are taking into account and what procedures are in place for obtaining information about staffing arrangements. This should include, but not be limited to data in relation to patient safety and quality of care measures and outcomes, patient feedback and adverse event reporting. RAG status Item Clearly defined systems and processes are in place, and utilised, in all NHS functions and professional groups to ensure that when the Health Board is planning or securing the provision of health care from another person, it has regard to the guiding principles for health and care staffing and the need for that person from whom the provision is being secured to have appropriate staffing arrangements in place. Please provide information on the steps taken to comply with section 2(2) Please provide information on how these systems and processes, and their application, have improved outcomes for service users Comment work is underway to ensure that as part of any externally commissioned service we have safe staffing embedded as part of the quality assurance and monitoring framework.
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27 Areas of success, achievement or learning Areas of escalation, challenges or risks Level of risk (RAG) This is the residual level of risk, taking into account the actions taken. Level of Assurance: Please indicate level of assurance provided Declaration: The relevant organisation has systems and processes in place to meet the requirements of this duty, and has carried out this duty through the presence and use of appropriate systems and processes as detailed above. Please provide details of areas of escalation where the relevant organisation has been unable to achieve or maintain compliance or any challenges or risks associated with carrying out the requirements, and the actions in place to address these. Action This should describe what actions have been / are being / will be taken to address the situation. For example, engaging with service providers to ensure they understand what information is required, seeking alternative service providers etc. Limited assurance Area of escalation / Challenge / Risk Details This should include details of the NHS function / professional group etc. that the area of escalation, challenge or risk relates to. This should describe the situation: what is the challenge or risk identified? For example, there may have been difficulties in planning or securing services from in a particular speciality in relation to having regard to the need for that service to have appropriate staffing arrangements in place. Please provide details of areas of success, achievement or learning associated with carrying out the requirements. Area of success / achievement / learning Details Further action This should include details of the NHS function / professional group etc. that the area of success, achievement or learning relates to. This should describe the situation: what is the success, achievement or learning. This should describe what actions have been / are being / will be taken to address the situation. For example, if there is difficulty in recruiting in a particular speciality or remote / rural location, the relevant organisation may have investigated retire and return schemes or upskilling and career development for existing staff. It may also have looked at how the service could be redesigned.