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

Transcription

1 Human Resources/Organisational Development Report Purpose of report [For information/discussion/approval] Report to: Board of Directors Date: 2 October 216 Presented by: Executive Director of HR/OD Prepared by: Ann Stringer/David Thompson EWE Enc4 Sickness absence is at 4.16% for September which is higher than the previous year (September 215 was 3.65%). Work has concluded on phase 1 of the NHSI-led Culture Programme pilot with a summary report produced and shared. The trust will embark on phase 2 (design) in October. The GMC report on junior doctors training experience has raised some cause for concernactions are underway to address issues. Executive summary The Trust has been presented with the Gold Award for Better Health at Work. The Trust have also been recognised for their work with apprentices, winning the EON Regional Award for Macro employer of the year for the delivery of the Apprenticeship Programme. Finally we have been working with the Armed Forces to increase the health employment opportunities for Veterans and have been awarded the Ministry of Defence Silver Employer Recognition Award for our participation in the Stepping into Health (SITH) project. As part of this work representatives from the Trust have been invited to a round table discussion with HRH Prince William on the 12 th October 216. Q2 216/17 figures for both Appraisals and Statutory & Mandatory Training are ahead of plan for the year (against the Business Unit plans). The Workforce Report gives an overview of the key strategic areas of assurance, workstreams/associated action plans and progress to date within key areas. Risks associated with this report Trust Board are to be assured that CQC/NHSLA requirements are met Assurance Framework reference The following Board Assurance Framework references cover this report 1.5, 2.1, 2.2, 2.21, 2.22, 2.3, This report has previously been presented at: Workforce Committee The topics Northumbria included Healthcare in this report NHS Foundation were discussed Trust at workforce committee since the last Board report. The paper Workforce was not Strategy presented. Report to the Board of Directors, October 216 Finance, Investment & Performance Committee Safety & Quality Committee Workforce Committee Integration Committee 1 Patient Feedback sub-committee Executive Management Team

2 Date of Sub-committee Meetings: Workforce Committees (21 st April/19 th May/16 th June 216, 14 th July, 15 th September, 13 th October 216.) 1. Minutes are located on the Trust intranet 2. Our key strategic performance indicators 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. 1. Organisational Development Activity and Progress We have continued to deliver a series of organisational development activities including programmes to support NCUH. The activity from June September 216 is detailed below: Programme Number of Sessions Number of NHCT Participants Number of NCUH Participants Other/ Wider NHS Network Trust 18 Strategic Leadership Programme NPC Strategic Development Days 2 24 Continued Professional Development for OSM/GM/DD 1 4 Change Management 2 25 Consultant 5 Day Programme 2 22 Consultant Recruitment training Staff Nurse Leadership Programme Cohort 5 Specialist Nurses development day North East Patches conference support 1 16 LEA (Leadership Effectiveness Analysis) 5 5 Coaching - Internal 4 4 Trust 18 coaching External executive coaching 8 8 NHFML ( commencing again October) IT development Days 2 24 Assessment Centres July September Psychometric reports in July

3 Psychometrics reports in August Psychometrics reports in September Total Psychometrics Aptitude/error checking in July 4 4 Aptitude/error checking in August Aptitude/error checking in September Total aptitude/error checking Overall Total Transformation team contribution to OD and organisational culture and efficiency The team manage a portfolio averaging 25 concurrent projects. Projects have provided a wide range of service improvements with value estimated at 1.4m p.a.. Existing / recent projects New projects : NSECH Pharmacy Review - report shared with sponsors and stakeholders; including - improved speed/ availability of discharge medicine. The Stepchange project has been handed over to HR Recruitment with ad hoc support available as required, evaluation report is being produced. Cohort project (shared service for Occupational health) is live for Northumbria and Northumberland Council and enables contract income to be delivered. Full lessons learned evaluation to be completed as the project has been particularly challenging and over ran (as a result of supplier/ IT/ data issues). Finance Payroll review - benchmarked service/ fed back to stakeholders; completing dashboard system specification and closure report. Well Organised Ward - 6 areas complete with 6S on final wards in July, achieving over 63k in stock returns. Received positive feedback regarding standardisation and ease of finding kit; closure report to be produced. On-going/ expanded delivery of training across a range of audiences to build QI capability and capacity (Foundation degree, SAS doctors, Junior Doctors, Graduate Trainee, OSM development days, degree course, also via project work). Stop Before your Op on-going support for smoking cessation project, expected to expand in to smoke free site. Supporting WIMS project with combination of benefits realisation, process mapping and engaged in nurse documentation review. Review of base site delayed discharges in support of addressing the NSECH flow; options reports produced, key element use of Estimated Date of Discharges, Red/ Green days progressed to pilot on wards on wards 2, 5 (Wansbeck) 18, 24 (NT). Microbiology Review: initial assessment/ observation/ definition. Capacity and Demand Planning: Gynae Mental Health Service for Older People: improve ward task allocation/ completion and function of MDT. Process mapped and devised task management tool. Academic Health Network: Innovation scouts, Regional Q, Flow site accreditation. 3

4 Occupational Therapy pathway review. Colorectal- capacity and demand Nursing Dashboard Specification NSECH Ward 1 & 2 Out Patients Real Time Clinic Letters Organisational Change pathway Surgical/ Pregnancy Assessment Patient Flow Requests for : Occupational Health Phase 2 -On line Managers referral module and on-line Preemployment checks module Streamlining HR regional integration Additionally, the team is engaged in a continuing review of the trust s approach to QI, working collaboratively with Quality Lab to provide a step changes in transformation, performance, project assessment/ delivery/ coordination and training. Culture Programme Pilot Phase 1 is now fully concluded and a summary report produced detailing the key conclusions which emerged from the deployment of the 5 diagnostic tools. Prior to the production of the summary report, a synthesis workshop took place to review the findings with support from Michael West and the NHS Improvement programme team. Progress updates were shared with Board, EMT, Workforce Committee and Trust partnership as part of the wider engagement and communications plan. Phase 2 (the design phase) will commence in late October and will focus on the design of a collective leadership strategy for the trust. Representatives of the trust have also been engaged in contributing to a wider community of practice relating to the culture programme and speaking at NHS Expo 16 about the trust s experiences so far. Development of Nursing Strategy HR/OD were commissioned to research and produce a Nursing and Midwifery staffing strategy for year 216/217. This was designed to identify challenges in the N&M workforce and what steps are needed to address these in order to deliver patient care. The strategy contains 4 workstreams: Retention, Attraction, Recruitment and Development and regular updates are provided at a number of forums. Retention A survey was designed and deployed to assess the current mood in the nursing & midwifery community in terms of engagement, morale and job satisfaction. 6 core themes were assessed including: Feeling valued and recognised Feeling supported Health & wellbeing Promotion and progression Career intentions What s most important to you 13% of the staff group responded (373 staff) and the findings have been shared with the Board (at a recent Board development session), Chief Matrons, Senior Nurses Forum, EMT, Workforce Committee and Trust Partnership. An action plan has been developed to focus on the key areas of concern and this is reviewed monthly at the Chief Matrons meeting. The survey findings included: 4

5 Some evidence of low morale, job satisfaction and engagement amongst the current nursing and midwifery community A combination of staff shortages, the pace and frequency of change and limited progression and development were key contributors to this Camaraderie and team support was core strength in the feedback and there were examples of great leadership in practice Attraction We have designed and introduced a welcoming opening paragraph for all nursing and midwifery adverts. Further work to be undertaken on standardising content of adverts and ensuring that categories on stepchange and adverts are selected correctly. We are also reviewing all recruitment documentation in regards to branding. Fortnightly meetings with Chief Matrons, R&S and Communications are progressing well. We are representing the Trust at Job Fairs and also held a Northumbria Nursing event on Saturday 8 October 216. Recruitment A Nursing Dashboard has been designed to show a snapshot of nursing recruitment and nursing headcount on a monthly basis. An escalation plan is in operation to review all recruitment files older than 6 weeks. The Regional Streamlining activity has also commenced aimed to standardise and improve Time to Recruit. Development The trust is committed to developing a constant pipeline of nursing talent and combining growing our own talent with getting the best of the nursing and midwifery talent available externally. There are a number of streams of work contributing to this including: APEL 18 month programme with 1 students now in their final year (Y3) Trainees on the OU programme BSc (Hons) in Adult Nursing The Return to Practice programme is in progress with 12 returning qualified nurses A series of career pathways maps have been produced and are evolving We are engaged in national and regional Higher Apprenticeship trailblazers for Nursing We have contributed to a regional bid for places on a 2 year Nursing Associate pilot programme commencing in January 217 Supporting the Commercial Strategy - Development of Car Leasing Workforce Following approval of a revised structure for car leasing, consultation with existing staff has now successfully closed with the internal sales team moving to a spot salary and bonus dependent upon sales volumes and other behavioural key performance indicators. We have also now successfully appointed to the National Account Manager post and will commence on the Regional Account Managers. Work is to be commenced on amending the appraisal system for this group to make it more commercially focused and developing a training plan that fits their needs. 2. Benchmarking information and comparisons The table below shows our regional and national benchmarking in the Juniors Doctors survey undertaken each year by the GMC. You will note that performance has declined sharply in the last 12 months. We have pulled together an action plan to address those issues that we can some issues relate to the level of facilities available at the new site, and the increased pressure on resources and beds. 5

6 3. Learning and Development Activity and Progress The Care Certificate (CCP) The Care Certificate programme has been running since October 214 incorporating 25 cohorts of Nursing Assistants and Nutrition Assistants who are new to care or new to the trust. The programme delivers the fundamentals of patient care, focusing on the attitudes, behaviours and values required to deliver dignified and compassionate care. We have also included health apprentices since June this year and this will continue. The programme is delivered immediately after trust induction to ensure that staff have the fundamental knowledge they require, before entering the clinical areas. To date, there have been 34 staff who have undergone the care certificate induction, 6 staff are currently on programme, 222 have completed the Care Certificate and the remainder are on long term sick leave/maternity leave or have left the Trust. There have also been 11 staff members who have completed the Northumbria Certificate of Care, as their job role does not allow them to achieve all 15 standards in the care certificate. The programme is 6

7 supporting the new role of Advanced Technical Officers (ATO) this is a combined patient care/pharmacy post. Individuals have attended the fundamental sessions to support their new role. The programme also includes a scenario day 5 months after commencing in the trust, this is to consolidate their learning and ensure that staff are still displaying the expected behaviours and values, we are now using the DASH facility at WGH to deliver this. Apprenticeships Our commitment to recruiting and developing a future workforce via Apprenticeships continues with a focus on Business Administration and Health. An Apprenticeship Levy update paper is due to EMT this month. A Task & Finish group has been established and meeting regularly to focus on this, with representation from Learning & development, finance and clinical areas. Meanwhile, the trust is actively engaged in regional conversations relating to the Levy and information events have been held at HEE. NE and Nissan. There are regular update on the progress of the Levy via the department for Business, Innovation and Skills, Apprenticesships.gov and the Skills Funding Agency. Further guidance for employers, on the calculation of payments, is expected from HMRC in December. All public sector organisations will be required to employ 2.3% of the workforce in apprenticeship roles, the Public Sector duty, this will represent a significant increase in the number of apprentices for NHCFT On the 6th of October NHCFT won the E.ON Regional award for Macro employer of the year for the delivery of Apprenticeship programmes. 12, employers across the UK entered this award. Regional winners will progress to the next stage of the competition, where their applications will be assessed by a national judging panel. National finalists will be announced in early December and will be invited to the national ceremony on 2 January 217 at the Grosvenor House in London. National Graduate programme Current trainees are continuing well within all work placements and the programme is continuously developing to help improve areas in order to enhance the delivery for the new cohort planned for 217. All General Management Trainees were offered an exciting opportunity to apply for a 12 month secondment within NHS Improvement to work with the national A&E/ED project, from this initial application stage 2 trainees have been requested to attend a second interview on the 13th October 216. The year 2 Postgraduate Trainees have also be given an opportunity to apply for a band 5 role within the Surgery Business Unit to support progression within the programme. Undergraduate (Internal Programme) Year 1 2 trainees Year 2 4 trainees Year 3 1 trainee Postgraduate (Internal Programme) Year 1 5 trainees Year 2 4 trainees Over the coming months we will be agreeing the planning stages of the next cohort which will commence on programme in August 217. More information will be available within further updates. Civil Service Graduate programme We did not receive an autumn graduate in our role as a placement host for the Fast Stream Civil Service graduate programme but are hopeful we will be selected again for spring 217. The success of the scheme and the quality and calibre of these graduates means that more organisations are applying to be hosts so it is becoming more competitive. 7

8 Coaching Substantial work has been taking place to develop the Coaching strategy, action plan and supporting processes to embed the coaching faculty within the trust. A number of coaches are now fully qualified having satisfied the Institute of Leadership and Management s requirements to coach independently. The trust has also become a member of the Associate for coaching which gives us access to useful resources to support the continuing professional development of our coaches. Step Into Health Programme - Promoting NHS Careers to Armed Forces Service Leavers and Veterans. Step Into Health Programme (SITH) - Promoting NHS Careers to Armed Forces Service Leavers and Veterans. The Trust has recently been awarded the Ministry of Defence Silver Employer Recognition Award for our participation in the SITH project, HRH the Duke of Kent will formally present the award to Ann Stringer on the 1 th of November 216. Trust representatives have also been invited to Basingstoke and North Hampshire hospitals FT, on the 12 th of October 216, to discuss the SITH project and to meet HRH Prince William with a view to raising the profile of the project to a national level. The most recent Step into Health Information Day held at Cobalt on the 6 th of October, again has evaluated really well and attendees provided some very positive and useful feedback. The Trust has been able to offer ten individuals relevant work placements to date, and one individual has successfully secured a position with the Trust and another is currently going through the application process for a substantive post. Placements are across a range of specialities, including Learning & Development, Security Porters, Catering, Nursing, Management and most recently, Engineering. Next steps include promoting the SITH project to other FT s regionally and nationally and the next event is planned for the 21 st of February 217. Future funding for the Step in to Health project remains unclear at this point, it is hoped that several high profile public events may lead to additional funding from Health Education England and FT s. 4. Health and Wellbeing recognising the link between staff health and wellbeing and patient outcomes 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: The Trust s involvement in the Exemplar Employer (NHS England Healthy Workforce programme) has been instrumental to the further development of initiatives designed to improve the Health and Wellbeing of our staff. We are in close contact with NHS England partners and are required to give regular updates in respect to key areas of the programme. Northumbria was assessed against the Gold Award of the Better Health at Work Award in July. As a result of this assessment, we are proud to announce our achievement of our gold award. Many thanks go out to all who have supported the trust in gaining this award. Commencement of 2 health trainers to support existing health and wellbeing programme. Health Trainers will work with members of staff to help create lifestyle changes and signpost to relevant services/initiatives. These have included promotion of self-referral to physio, headspace code, referral to staff weight management programme, on site trust gyms and physical activity discounts. 8

9 We have submitted an action plan to Northumberland CCG as required for health and wellbeing CQUIN target Introduction of health and wellbeing initiatives. CQUINS also includes; - Healthy food for NHS staff, visitors and patients - Improving the uptake of flu vaccinations for front line staff within Providers We continue to work against our action plan and have no other requirement than to deliver against our action plan which includes our annual beat the board campaign. Commencement of Health and Wellbeing road shows run by health trainers. North Tyneside road show met with huge success and engagement levels. We plan to run further road shows at Wansbeck, Cobalt and Hexham. We hope to roll this out to community sites also including Alnwick, Foundry House and Eddie Ferguson house. Road show includes promotion of all on offer as a staff member. Further publicised the offer given to staff in the trust to access to Headspace codes. This was done via a 2 page article within the staff magazine. Headspace is a mindfulness resource that is available via a web app or via web site. To date approx. 6 codes given out and ask if you could all promote this great offer within your teams and/or departments. Roll out of staff weight management programmes. A six week programme and each session will last approximately 4 6 minutes for staff members who have a BMI greater than 25kg/m2 and /or a waist circumference of 37 (94cms) for a male or 31.5 (8cms) for a female. The sessions will be delivered by a dietician with support from a health trainer. There will also be a psychology session included as part of the programme. Sites are as follows for quarter 2: North Tyneside General Hospital Wansbeck General Hospital Cobalt Other sites are to be booked and promoted via communications including Cramlington, Hexham and Alnwick/Berwick. The Exemplar Employer Steering Group continues to meet to review progress to date. Recent spotlight on Healthy food environment which includes ensuring patients always offered healthy food on site. A traffic light system has been implemented to help staff and patients make healthy food choices. Work has commenced on standardising single portion sizes given to staff and patients. Work continues to ensure that 3% of products in vending machines dietician approved and meet the limits set by NHS England on high fat high sugar content. In addition branding of vending machines is being reviewed to remove overt reference to high sugar drinks in favour of healthy options. Work with Learning and Development to offer a health and wellbeing section on apprentice induction. First session to be October 216 to encourage leading a healthy lifestyle Leading a Healthy Workforce training continues to be delivered. Courses have been scheduled in to comply with NHS England target of having 5 manager trained across 5 programmes. To date we have delivered 4 programmes to over 4 line managers. Managers are targeted through areas of highest sickness/absence. NHS England Health Survey rolled out 2-3th June. Staff completing survey received a personal health report based on health information supplied in questionnaire. This survey acts as a baseline measure for the organisation at this time. We are awaiting a final tally of responses. This will be reviewed via the Exemplar Employer Steering Group. Drafted plan for roll out of NHS Health Check to eligible staff aged Roll out will include 3 areas which are: Opportunistic road shows for example 9

10 Letter Invite per business unit Onward Referral including Occupational Health nurses, physio, appraisals etc. Road shows have commenced and letter invites to commence Jan following flu vac period. Any staff member not within this age range can receive a MOT Health Check in replacement to NHS Health check. Following success of physical activity Beat the Board challenge in 215, we are agreed to launch our 216 challenge for November 216. The Board have agreed to enter a team so we are currently working with communications to publicise - again would appreciate support to encourage participation in your teams/departments. Continue to establish and promote local physical activity to staff. On site classes and running groups continue and look to introduce new classes. The promotion of local gym discounts and sporting opportunities continues on the intranet. Visit to the trust on behalf of NHS England to showcase the work that is on-going around health and wellbeing. Visit was successful and comments made on wide range of service/initiatives staff can access. Scoping meeting for evaluation of NHS England meeting took place in August. The company commissioned to carry out this scoping will confirm the metrics to be used to measure our progress. 5. Progress and Achievement of Key Performance Indicators Recruitment Time to Hire The introduction of a software product called stepchange has allowed the recruitment team to break down the time taken to complete the various steps in the recruitment cycle. Due to our participation in the regional streamlining work stream we are now aware that we are one of only two Trusts in the region who track time to hire. Whilst there is clearly still much to do this reporting provides a framework for on-going process improvement work. Due to some alignment of priorities we have seen a significant reduction in the time to hire of qualified and unqualified nursing staff. Stepchange Report - Recruitment Statistics Task APR MAY JUN JUL AUG SEP Status 4-Oct-16 Adverts processed Requisitions in progress 134 Interviews processed Vacancies in progress 54 Offer Letters issued Pre-Employment Checks 343 Contracts issued Start dates agreed Month Average of Requisition approval to Last Pre- Count of starters Employment Check Apr Note: These figures are only for starters who were offered a post from 1st July 215 onwards May Jun Jul Aug Sep Average/ Total

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14 Sickness absence results The Trust's SAR% for Q2 Jul-Sep 216/17 is 4.9% which is only a slight increase change on Q1 (which settled at 3.98%). The last 12 months rolling sickness absence results are as shown in the table below: 14

15 Sickness % Sickness Absence Rate - Oct Sep % 5.% 4.% 3.% 4.5% 4.32% 4.45% 4.72% 2.% 4.18% 3.85% 4.% 4.% 3.95% 4.11% 4.1% 4.16% 1.%.% October Novem ber Decem ber January Februar y March April May June July August Absence Rate % 4.5% 4.32% 4.45% 4.72% 4.18% 3.85% 4.% 4.% 3.95% 4.11% 4.1% 4.16% Trust Target 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 12 Month AVE % 4.5% 4.18% 4.27% 4.39% 4.34% 4.26% 4.22% 4.2% 4.17% 4.16% 4.15% 4.15% Septem ber 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. The 12 month RYA for the Trust is now at 4.15% which is almost the same as the previous 12 months (4.14%). The introduction of the new Health at Work Policy will also assist in helping support and manage sickness absence going forward. The sickness absence level in Estates & Facilities/NHFML continues to be of concern (7% in July and 6% in August) and detailed work continues to fully understand and manage this down As part of the nursing strategy we are focusing on the sickness absence level of nursing staff. The results by occupational group are as shown below. Absence Timeline - N&M Registered Staff Group Only Absence Long Term / Short Term - N&M Registered Staff Group Only Absence Days Abs (FTE) Avail (FTE) Absence % (FTE) 4.54% 56,867 37, ,89.78 Labour Turnover Labour turnover is currently at 1.68% (Headcount); 8.22% (FTE) compared to last quarter s 9.83% (Headcount); 8.15% (FTE). This remains low but has increased slightly. 15

16 Labour Turnover by Business Unit - Oct Sep % 16% 14% 12% Headcount FTE Leavers Headcount Leavers FTE LTR Headcount % LTR FTE % Trust LTR FTE % Trust Headcount LTR % 319 Northumbria Healthcare 1% NHS Foundation Trust 11,686 7,71 1, % 8.22% 8.22% LTR Headcount 1.68% % 319 CHI Child Health Directorate 8% % 9.18% 8.22% 1.68% 6% 319 CLI Clinical Support % 9.45% 8.22% 1.68% 4% 319 COM Community Business Unit 1,793 1, % 7.54% 8.22% LTR FTE 1.68% % 2% 319 COR Corporate Services % % 6.39% 8.22% 1.68% 319 MED Emergency Care and Medicine Business Unit 1, , MED 319 SUR % 319z 9.8% 8.22% 1.68% 319 COM Emergency Emergency Northumbria 319 SUR Emergency Surgery & Elective 319 Care CHI Business 319 Unit CLI 319 COR 1,692 1, EST % 5.87% 319z 8.22% Trust 1.68% LTR FTE % Community Care and Surgery & 319 Staff Healthcare 319 EST Estates and Facilities Child Health Clinical Corporate Estates 89 and % 14.6% Northumbria Business Medicine Elective Care Bank Facilities 8.22% 1.68% 319 Staff Bank Directorate Support Services Unit 3,44 Business. Business 517 Facilities. 15.3% #DIV/! Primary Care Managemen 8.22% 1.68% 319z Northumbria Healthcare Facilities Management Ltd 281 Unit Unit % t Ltd 9.59% 8.22% Trust 1.68% Headcount LTR 319z LTR Northumbria Headcount Primary % Care 9.94% 9.51% 8.25% 6.68% % % % % 11.71% 12.81% 11.14% 11.71% 8.22% % 1.68% LTR FTE % 9.18% 9.45% 7.54% 6.39% 9.8% 5.87% 14.6%.% 9.59% 11.14% Trust LTR FTE % 8.22% 8.22% 8.22% 8.22% 8.22% 8.22% 8.22% 8.22% 8.22% 8.22% Trust Headcount LTR % 1.68% 1.68% 1.68% 1.68% 1.68% 1.68% 1.68% 1.68% 1.68% 1.68% In line with our nursing strategy the labour turnover for nursing staff is as shown in the table below Statutory and Mandatory Training and Appraisal For 216 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. The relevant managers and business units are held accountable for their performance at Workforce Committee. Appraisal completion For Q2 216/17, overall compliance is standing at 41.3% (as at the end of September 216) which is very slightly ahead of plan (4.5%). 2 departments were due to complete their Appraisals against their plans by end of September departments are compliant (44 of which are 1%). 7 departments are between 5-84% with the remaining 6 departments being less than 5%. Monitoring will continue to be made against all Business Unit plans for the rest of the year with target for completions being end of Q3, December 216. Work is underway with Business Units and Medical Staff to more closely align the appraisal individual objectives with Trust Strategy. Statutory and Mandatory Training for 216/217 16

17 Overall compliance is standing at 78.7% (as at the end of September 216) which is massively ahead of plan (48.4%). 2 departments were due to complete their Statutory and Mandatory training, against their plans, by the end of September departments are compliant (13 of which are 1%). 99 departments are between 5-84% with the remaining 2 departments being less than 5%. Many other departments have started their training ahead of schedule which has contributed to the overall high compliance rate at this time of year. We need to be mindful that the Well Led Review stipulated that both statutory and mandatory training and appraisal compliance should have a higher target than 85%. 6. Audit, Risk and Assurance Reporting 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. European Working Time Regulations (EWTR) The EWTR group have now assessed the Trust position in relation to compensatory rest and a paper will be submitted to EMT for further discussion. It is clear there are a plethora of different arrangements in place, with most providing access to paid time off in lieu which is in excess of the requirement to provide compensatory unpaid rest. The existing time and attendance system is to be replaced in April 217 and the current Klikview reporting module is proving problematic. This may reduce reporting ability between now and the implementation date of the new system. Outcome of Internal Audit The findings of audit NAM1516 resulted in a finding of limited assurance. This related to the preemployment clearances of agency staff (Surgical Business Unit) and bank staff (HR recruitment team). As a consequence of this outcome Ann Stringer attended audit committee to explain the proposed action plan. Many of the actions have already been addressed. Additional audit checks have been agreed (to be completed by the HR team) with Audit committee. Agency staff will be audited in October 216 and recruitment files for Bank have been audited in September 216 with a 97.3% accurate completion standard. This is to be discussed at October workforce committee Introduction of new Junior Doctor Contract. Progress is being made to introduce the revised terms and conditions from December 216 for Foundation Year One trainees. Progress is in line with the action plan. No further details of any proposed industrial action have been received. Reliance on bank and agency staff A total of 27,21 bank shift requests were filled and worked in Q2 (Jul-Sep 216) which is an increase on Q1. Of these 92% were undertaken by the Trust's Bank Staff and 8% were undertaken by Agency Staff. 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. 17

18 For the 92% of Bank shift requests worked 76% of those who worked the shifts are also substantively employed by Northumbria. The remaining 24% are employed by Northumbria as bank staff only. Requested Shifts Filled Jul-16 Total By Bank By Agency Trust Total By Requested Shifts Filled Aug-16 Total By Bank Agency Trust Total By Requested Shifts Filled Sep-16 Total By Bank Agency Trust Total Combined Total for Q2 Jul-Sep 16 Requested Shifts Filled Q2 Total By Bank By Agency Trust Total % 8% Bank and Bank/Substantive Contract Analysis - Jul - Sep 216 Bank Only Bank and Substantive 24% 76% This detail should provide assurance to the Board that 76% of bank staff also have a substantive contract with the Trust. 7. Raising Concerns at Work (Whistleblowing Regulations) Quarter 2: July - September 216 During Quarter 2 there was one concern raised. Reference numbers have now been added to ensure traceability of cases. Information is based on formal 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 Raising Concerns policy) Raised as a formal whistleblowing concern Action Taken 18

19 RC45 Surgery Compromising patient care No Case Closed Relates to a concern raised by a staff member following a change of role. Informal Investigation - no further action Quarter 1: April June 216 During Quarter 1 there were 3 concerns raised. Reference numbers have now been added to ensure traceability of cases. Information is based on formal concerns or concerns raised via another route where the reported concern would fall within the whistleblowing definition. Ref Business Unit RC42 Surgery Nature of Concern (as defined by Raising Concerns policy) Compromising patient care Raised as a formal whistleblowing concern No Action Taken Case On-going This is linked to a Grievance process for which there is an appeal hearing scheduled w/c RC43 Community other No Case Closed Relates to a concern raised by a member of the public about a member of staff Safeguarding found staff member acted appropriately in this instance and that this is a malicious complaint. No further action to be taken RC44 Medicine other No Case Closed Relates to an outcome of a Grievance appeal concerning pregnancy risk assessments. Summary: April 216 September 216 Number of concerns 4 Quarter: - Quarter Quarter 2 1 Business Unit: - Child Health - Clinical Support - Community - Corporate Services - Estates & Facilities - Medicine - Surgery - NPC - NHFML Nature of concerns: - Compromising patient care - Ill treatment of a patient by a member of staff - Fraud/Financial irregularity - Corruption, bribery or blackmail

20 - 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 Freedom to Speak Up Guardian This role has been successfully recruited to and the successful applicant will soon commence a tailored induction and familiarisation programme. This person will provide updates to Trust Board on whistleblowing issues and remedial actions. 8. Recommendation to the Board of Directors Trust Board is asked to note the contents of this report. ANN M STRINGER Executive Director of HR/OD DAVID THOMPSON Non-Executive Director 2