Minute of the above meeting held at 2:00 pm on Tuesday 14 March 2017 in the Board Room, Kings Cross, Hospital.

Item 3.1 Please note any items relating to Board business are embargoed and should not be made public until after the meeting STAFF GOVERNANCE COMMITTEE Minute of the above meeting held at 2:00 pm on Tuesday 14 March 2017 in the Board Room, Kings Cross, Hospital. Present Mr George Doherty, Director of Human Resources & Organisational Development, Mrs Judith Golden, Employee Director, Tayside NHS Board Mr Munwar Hussain, Non Executive Member, Tayside NHS Board Mrs Alison Rogers, Non Executive Member, Tayside NHS Board Mr Hugh Robertson, Non Executive Member, Tayside NHS Board Professor Margaret Smith, Non Executive Member, Tayside NHS Board Mrs Sheila Tunstall-James, Non Executive Member, Tayside NHS Board Apologies Ms Jenny Alexander, Co-Chair Workforce and Governance Committee, Professor John Connell, Chairman, Tayside NHS Board Dr Andrew Cowie, Area Clinical Forum Chair, Ms Margaret Dunning, Board Secretary, Mr Raymond Marshall, Staff Side Representative, Ms Lesley McLay, Chief Executive, In Attendance Mr David Gordon, Professional Lead for Staff Support, Spiritual Care, Ms Jenni Jones, Associate Director of HR and OD- Development, Mr David McFarlane, Associate HR Business Lead, Mrs Jennifer Mudie, Associate Director of HR and OD - Governance, Mr Christopher Smith, Associate Director of HR and OD - Relations, Mr Munwar Hussain in the Chair 1. Chairman s Welcome and Introduction ACTION Mr Hussain welcomed all to the meeting especially Mr David McFarlane, Mr Scott Dunn, Mrs Pat Millar, Ms Gaynor Dickson and Mr Charles Sinclair, the new Associate Nurse Director for. Mr Hussain added that as the Terms of Reference had been amended and approved at the December 2016 meeting he now welcomed Mrs Judith Golden, Employee Director as the new Co-Chair of the Committee with Mrs Alison Rogers remaining as Non-Executive Vice-Chair. Chairing of the meeting would now rotate between Mr Hussain and Mrs Golden. 2. Apologies The apologies were as noted above. 40

3. Minute of Previous Meeting 3.1 Minute of Meeting held on 13 December 2016 The Staff Governance Committee Minute of the meeting held on 13 December 2016 was approved on the motion of Mrs Alison Rogers and seconded by Mrs Judith Golden subject to the following amendments:- Page 28 - Item 6.1 STAR Awards second bullet point should read :- A Short Life Working Group has been meeting regularly//... Page 34 Item 9.4 Valuing People Valuing Personal Development Plans the final paragraph should read:- The Committee noted that Mrs Millar routinely reported the update of e-ksf throughout the Organisation. Page 35 Item 9.4 Valuing People Valuing Personal Development Plans the paragraph starting Mr Hussain agreed should be removed. Page 36 Item 9.6 Non Executive Whistleblowing Champion April to September 2016 Report) the first paragraph should read:- Mrs Rogers advised the report was a 6 monthly update on issues raised through the Whistleblowing Policy only//... 3.2 Committee Chair s Assurance Report Staff Governance Committee Minute 13 December 2016 Mr Hussain advised that this report had been presented and noted by Tayside NHS Board Noted the Committee Chair s Assurance Report 13 December 2016 3.3 Action Points Update The Action Points Update was approved by the Staff Governance Committee with the following highlighted:- Item 7.3 Well Informed Ms Dickson advised that Communications were restarting engagement events to areas across Tayside with various Senior Managers. Item 9.7 Staff Governance Terms of Reference this item is now complete. 4. Matters Arising There were no matters arising 5. Declaration of Interests There were no declarations of interest. 6 Presentations 6.1 Spiritual Care Staff Wellbeing Service 41

Mr David Gordon provided the Staff Governance Committee with an update on the Staff Wellbeing Service which was launched in 2013. He indicated the service was self referral with numbers using the service doubling in the last 4 years. The Service was receiving 25 new staff members per month for 1:1 consultations. The Service was hosted nationally by NES. Counselling used many different types of therapy which was aiming to change the culture at work. Work was being undertaken with the University of Dundee and 3 rd Year students and could also be used to support newly qualified practitioners. Asked how the Service was approaching GP Practices and were advised that discussions were taking place to try and target GP Practices alongside Dr Michelle Watts. The themes running through the service were workload issues however personal issues were also a major part of discussions. Had queries as to how the impact of the service was monitored. Mr Gordon advised that performance statistics were available however there was no way to measure the success of the Service. Noted the verbal update. Recognised the excellent work being carried out and the links to wellbeing at work. 7. Staff Governance Standards 7.1 Staff Governance Standard - All Staff are Appropriately Trained and Developed (SGC/2017/09) Mrs Millar advised the report was prepared to inform Staff Governance around progress during 2016 of the Staff Governance Standard. The key elements are the following:- All Staff have a Regular Effective Personal Development Plan (PDP) and Review Discussion There Is a Workforce Learning and Development Strategy In Place All Staff Have Equity of Access to Training, Irrespective of Working Arrangements or Professional Resources Including Time and Funding Is Appropriately Allocated to meet Local Training and Development Needs A directory for statutory and mandatory training was also attached to the report with Health & Safety being highlighted as a major area. It was noted that the Chief Operating Officer was now attending Corporate Induction Programmes, and her sessions have provided positive feedback. Mrs Millar highlighted with the committee that relationships continue to be strengthened with Educational Colleagues to provide work placement opportunities for school children, which will ultimately strengthen our future workforce planning. Achievements around the success of the Young Scotland Programme were 42

commended. The Young Scotland Programme was an excellent programme and it was agreed that a presentation would be provided to the Staff Governance Committee in June 2017. The Glasgow Centre for Living was providing support around disability and diversity with Ms Sheila Hands supporting the agenda. The Organisation is benefiting from the invaluable work being carried out. Mr Dunn highlighted the range of developmental programmes provided by Organisational Development contained within the report. Mr Dunn highlighted the very successful Getting Connected series, an induction for senior multidisciplinary colleagues as well as the successful Promoting Leadership programme aimed at Clinical Leaders in particular. The Committee noted that LearnPro is used as the e-learning platform across (and NHS Scotland). Mrs Millar highlighted that work was underway to reshape online learning modules providing support and resources. It was highlighted that funding for LearnPro was written into the e-health budget, underpinning the e-health Strategy. A funding update would be provided to ensure sustainability in due course. The Lifelong Learning Partnership Agreement had to be signed off by the Staff Governance Committee and Tayside NHS Board. The Committee congratulated the team for their efforts and the quality of report. It was noted that Mr Doherty, Mrs Golden and Professor Connell had met with the Cabinet Secretary for Health to discuss work experience. Career Advisory Services would be looked into as well. It was noted that historically learning and development budgets had been devolved to service/directorates. It was not clear under Health & Social Care Integration what learning and development budgets were in place. PM PM PM Noted the update Requested an update on funding issues in March 2018 Agreed a presentation on the Young Scotland Programme be provided to the June 2017 meeting The Lifelong Learning Partnership Agreement was to be signed off by the Staff Governance Committee and Tayside NHS Board PM PM PM 7.2 Safe & Improved Working Environment (SGC/2017/01) Mr Doherty advised that the Chief Operating Officer, Mrs Lorna Wiggin was taking forward the Health & Safety Agenda. He noted that the strategic Health & Safety Committee was not meeting regularly however work was being undertaken to refresh and reframe this Committee to work more effectively. The Organisation was seeking to appoint a Head of Health & Safety and highlighted that the Service Level Agreement with NHS Fife had expired and this was a critical issue for. Mr Hussain asked if there was the possibility to acquire benchmarking against other Boards and it was noted that discussions were ongoing with a report being 43

framed around this issue. An external Consultant has been engaged to look at issues around the Organisation Regular reporting to the Staff Governance Committee would be required to ensure that Health & Safety was once again moving forward to ensure key risks were monitored. Noted the creation of the health & Safety Strategic Management Group and priorities for future delivery. Agreed consistent updated to ensure key risks were monitored. GD/LW 8. Governance Risks 8.1 Medical Workforce Strategic Risk (SGC/2017/02) Mrs Mudie advised there had been no changes in relation to the current risk. There were concerns around compliance of the Junior Doctors Rota which would incur penalties. Significant work was being carried out to mitigate this risk. Dr Cook was undertaking this issue. It was highlighted there were no assurances that local graduates would stay in Tayside and encouragement had to be given to ensure as many stayed as possible. It was agreed that information around the numbers of graduates which stayed in Dundee could be made available. The reputation of the Organisation was also key in ensuring graduates stayed in the area. JM At the last meeting of the Clinical Care Governance Committee John Davidson had highlighted the issues raised in relation to the Junior Doctors. He was visiting specific areas along with NES. There would also be a possible impact from the GMC visit in 2017. It was requested that Professor Russell be asked if there was an operational risk in relation to Junior Doctors. JM Agreed the number of Graduates staying in the area this year would be sought Agreed Professor Russell would be asked to look at an Operational Risk in relation to Junior Doctors staying in Noted the content of the Report JM JM 8.2 Workforce Optimisation (SGC/2017/03) Mrs Mudie indicated that discussions were taking place with Mrs Hilary Walker around redefining this risk. Noted the report Agreed that an update would be provided to the June 2017 meeting JM 44

8.3 Assurance Report on Nursing & Midwifery Workforce Risk (SGC/2017/04) Mrs Costello, Nurse Director introduced Mr Charlie Sinclair recently appointed Associate Nurse Director with lead responsibility for the professional portfolio for nursing and midwifery workforce. Mrs Costello advised there was a high level risk of exposure with actions being undertaken to mitigate the risk across the organisation and with a focus currently within Perth & Kinross. The Nursing and Midwifery Workforce is a key component of the Transformation Programme Board on both strategic and operational performance fora. It was noted weekly meetings with Heads of Nursing were established around assessment of risk, potential impact on patient safety, care and services around the workforce levels with regular reviews and actions being progressed to ensure nurse staffing levels meet patient need. Work was taking place to expand the numbers of personnel registered with the nurse bank. Reduction in the use of Agency staff being monitored through organisational governance aligned with the Workforce and Care Assurance Work stream. A full Attraction and Recruitment Strategy was published last February with work going well in some areas. Links were being forged with schools with organisational representatives meeting children. Mrs Mudie, Associate Director of HR and OD, Governance, would be happy to further update the Committee at a future date. It was advised that inclusion of the Datix report with the Committee SBAR was not helpful; information illustrated the 2 years history of the risk. Discussion highlighted that further consideration had to be given regarding the removal of bursaries for student nurses, however it was highlighted that there would be no changes for domicile students. Noted the report. 9. Monitoring Reports 9.1 Corporate Workforce Dashboard Staff Governance Committee and The Finance & Resources Committee (SGC/2017/05) Mrs Mudie advised this was a new reporting system. She talked the Committee through the new reporting arrangements. Any comments on the new report should be sent to Mrs Mudie directly. JM The Committee thanked Mrs Mudie for the excellent work. They highlighted that Disciplinary/Grievance information would be better served to be included within the People Management Practice Report provided by Mr Smith. Mr Robertson indicated that information should be collated within family groupings for ease of reference. A separate report should be utilised for absence reporting. 45

Mr Doherty highlighted the need for reporting to be meaningful and understand the impact this type of report would have in the future. The Directorate were looking to build a simple dashboard for patient and staff experience. Information relating to benchmarking against other Boards on similar reporting styles would be provided to the next meeting. JM Thanked Mrs Mudie for the dashboard reporting and agreed comments would be sent to Mrs Mudie 9.1.1 Workforce Information Report Quarter 3 Mrs Mudie advised that the reporting structure would remain until the year end. The new dashboard would be utilised along with supporting papers. The new dashboard report would also be presented to the Finance & Resources Committee along with relevant reports. The Staff Governance Committee :- Noted the report. 9.1.2. Promoting Attendance At Work Quarter 3 2016 2017 (SGC/2017/07) Mr Smith thanked Ms Bayne for the report she produced. He noted that absence rates had increased during Quarter 3 however this was in part due to the winter season. Areas such as Learning & Development, Support Services and Midwifery had additional actions put in place to help with issues around absence. This support has resulted in a significant reduction in absence rates within Midwifery. Stress and Anxiety rates were high however this was not always related to work issues. Queries were raised as to what the Organisation was doing to mitigate this serious issue. Mr Doherty advised that a number of years ago had a poor record around this however with excellent work from Mr Smith and his team, was now one of the best performing Boards in Scotland in this area. Steps had been taken to ensure staff utilised services such as the Wellbeing Service, Live Positive which helped provide a positive experience for staff. It was noted that figures in relation to the Integrated Joint Boards were not available however Mr Smith advised he would request this information. CS Mr Robertson asked how a return to work notice could have Unknown Cause and Mr Smith indicated this was a national definition and that staff had an obligation to provide a reason for absence. Noted the content of the report. Agreed Mr Smith would request sickness absence rates for the Integrated Joint Boards. 46 CS

9.1.3 Recruitment Activity (SGC/2017/08) Mrs Mudie advised that positions had been authorised for recruitment. Appendix A of the report showed the normal trend for a dip in recruitment. She highlighted there were a significant number of vacancies with Dundee Integrated Joint Board which had now been filled. Medical and Dental areas had their challenges however an emphasis was being placed on trying to recruit to posts. has a current 3.1% nurse vacancy which is below the national average of 4.1%. Noted the content of the report. 9.2 Item removed from Agenda 9.3 Valuing People Valuing Staff Experience & Engagement imatter as a Vehicle to Underpin an Improvement Culture (SGC/2017/10) Ms Jones noted with the committee that Scottish Government had now confirmed that the previous national annual Staff Survey be discontinued and that future national staff experience be measured using the imatter Continuous Improvement Model supplemented by a short complementary questionnaire. More details about the short questionnaire would become available in due course. Ms Jones advised that the implementation of imatter continues to meet key milestones and that by 31 st December 2017 all -employed staff will have the opportunity to participate in imatter. Ms Jones highlighted that both Dundee and Angus Health and Social Care Partnerships have advised that Social Care staff in integrated teams and/or assessment services will be participating together with NHS staff in these cohorts, offering an opportunity to understand where staff are currently (a baseline) as new working arrangements become embedded and for a more inclusive approach for employee engagement across the Partnerships. The committee noted that early discussions had commenced on the arrangements for embedding and sustaining imatter following full implementation across. Discussions and planning will continue with stakeholders over the coming months. Noted the content of the Scottish Government correspondence Noted the inclusion of the Social Care staff in Dundee & Angus Health & Social Care Partnership cohorts Noted the commencement of discussions on the embedding and sustaining of imatter Celebrated what had been achieved to date 47

9.4 Valuing People Development of a Whole System/Personal Development Review (PDR) & Personal Development Plan (PDP) Improvement Plan for 2016/17 Update (SGC/2017/11) Mrs Millar advised that the EKSF system that was in place to support the Knowledge Skills Framework is due to be replaced by another system in March 2018. There is now an opportunity to look at reinforcing the connections with KSF and imatter. Seniors Managers from Dundee Health & Social Care partnership have noted an interest in exploring a future model to support this.. It was noted that KSFs were locally owned by managers however it was highlighted that Mrs Millar carried out excellent work around KSF. A form or reporting had to be sought from local areas to ensure the Staff Governance Committee were updated around KSF. Mr Doherty advised this would be monitored through the Local Partnership Foras which would create a performance culture. This would help shape the future workforce and should be managed, owned and delivered locally. With the full support of our staff side representatives and leadership from the Chief Operating Officers, we will build on the current sources of evidence referred to, and align these reporting systems using the imatter toolkit, Nursing & Midwifery, AHP revalidation and RHCSW data, with a sign off section evidencing that staff have had an annual PDR/P discussion with their line manager. A test of this model (using template in Appendix 1) is piloted within a clinical and non clinical area of service. We are keen to explore connections with imatter being the main vehicle to support individual and team development. An evaluation report will be presented back to the Staff Governance Committee in September 2017. To provide an assurance regarding progress towards meeting this Staff Governance Standard, the 4 Chief Operating Officers will be required to provide status updates on activity. 9.5 Audit of People Management Practice (SGC/2017/12) Mr Smith advised that 6 monthly reports would be provided to the Staff Governance Committee and Area Partnership Forum around actions being required if necessary. Agreed an annual update on the use of the HR Audit Assessment Form would be brought to the Staff Governance Committee and Area Partnership Forum Agreed the Audit Assessment Form would be held centrally by the Director of Human Resources & Organisational Development Agreed a six monthly report on the employment compliance audits will be brought to future meetings CS CS 9.6 People Management Learning Directory (SGC/2017/13) 48

Mr McFarlane highlighted that the report outlined the pilot of the Directory that has been tested since July 2016. The Directory has been accessed by 100 Managers and it was intended to now have a graduated rollout. The Pilot has proved successful and has shown benefits with a user-friendly portal. The Directory helped to improve individual learning pathways and also provide teams with the necessary information to inform department training plans. The Pilot has encouraged an increased demand for training which needed to be measured in an incremental approach as the Directory is rolled out. Graduated rollout with each Directorate would also allow for evaluation and improvement to be ongoing through the process. Mr Doherty further added commendation for the work carried out. This type of initiative provided value for the Organisation. The Pilot also provided a passport to promote positive engagement. He supported the work carried out and for the Directory to be spread across the Organisation. The report was also discussed at the Remuneration Committee earlier today with the Committee looking to have a mandatory career development for staff. The Committee were advised there would be some administrative resources required to support the roll out. An oversight Group has been established to support the rollout of the Directory. The Staff Governance Committee agreed the following recommendations:- Implementation of Phase 2 of the Directory through graduated roll out, initially to pro-active Directorates a willing coalition of supporters. Development of the Directory within an e-platform that is a reflection of the quality and value we place on our People Development. Aligning of the Directory with similar and compatible work in the area of development e.g. Health & Safety, Statutory and Mandatory etc. Continued monitoring of the roll out via the oversight Group. The Group will consider ways we can continuously improve the Directory based on feedback from Staff 10. Annual Reports/Work Plans/Plans 10.1 Staff Governance Committee Terms of Reference Update (SGC/2017/14) Noted the updated Staff Governance Committee Terms of Reference and were advised these were agreed by tayside NHS Board 10.2 Employability Services Annual Report (SGC/2017/15) Mrs Smith advised students completing 32 week qualification based programmes are acknowledged through formal graduation events at the relevant College; those successfully completing 6 week Pre Employment courses are presented with Certificates of Achievement by managers. Miss Smith extended an invitation to Non Executives to attend pre employment celebration events and will ensure confirmed dates will be made available. It was noted that any issues related to funding that could affect the delivery of Employability courses will be brought to the attention of the Staff Governance 49 AS

Committee. Noted the report *11. *For Noting* - If Items Required Discussion Please Raise with the Chair 11.1 Area Partnership Forum Assurance Update 23 November 2016 (SGC/2017/16) Noted the Area Partnership Forum Assurance Update 23 November 2016 12. Items for Adoption 12.1 HR Policies (SGC/2017/17) Research Passport Policy The Staff Governance Committee endorsed the:- Research Passport Policy 13. Items for Information 13.1 Area Partnership Forum Minute 23 November 2017 Noted the Area Partnership Forum Minute 23 November 2016. 13.2 Joint Negotiating Committee Minutes 24 August 2016 Noted the Joint Negotiating Committee Minutes 24 August 2016 13.3 Joint Negotiating Committee Minutes 26 October 2016 Noted the Joint Negotiating Committee Minutes 26 October 2016 13.4 Joint Negotiating Committee Minutes 14 December 2016 Noted the Joint Negotiating Committee Minutes 14 December 2016 13.5 Record of Attendance Noted the Record of Attendance for information. 50

13.6 Scottish Workforce & Staff Governance (SWAG) 18 January 2017 - Noted the Scottish Workforce & Staff Governance (SWAG) 18 January 2017 14. Any Other Competent Business There was no other competent business 15. Date and time of the next meeting The next meeting of the Staff Governance Committee will take place on Tuesday 22 June 2017 at 2pm in the Board Room, Kings Cross Hospital. Subject to any amendments recorded in the Minute of the subsequent meeting of the committee, the foregoing Minute is a correct record of the business proceedings of the meeting of the Staff Governance Committee held on Tuesday 14 March 2017 and was approved by the Committee at its meeting held on Tuesday 22 June 2017. Chair.. Date 51