REPORT ON THE UPTAKE OF MANDATORY AND INDUCTION TRAINING OF FIRE AND THE ACTIONS TO IMPROVE COMPLIANCE RATES WITHIN THE UHB

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1 AGENDA ITEM 3.4 REPORT ON THE UPTAKE OF MANDATORY AND INDUCTION TRAINING OF FIRE AND THE ACTIONS TO IMPROVE COMPLIANCE RATES WITHIN THE UHB Report of Paper prepared by Assistant Director of Workforce and Organisational Development Head of Health and Safety Executive Summary The Chief Executive requested that the issue of the low level of Mandatory Training compliance in particular fire training be referred to the Workforce and Organisational Development in order to develop a plan to significantly increase The data shows compliance levels at only 19% for Mandatory Fire for the UHB as a whole, with some areas being in single figure percentage(april-november 2010) Induction training status for the last quarter of 2010/11 was at 22 % for modules, 46% for the year as a whole This is amongst the lowest in Wales The two above statistics represent a reduction in compliance since E learning has been introduced Induction and Mandatory Training are mainly via e-learning with a small number of tutor led sessions being delivered in areas where there is limited Uptake of Mandatory Training page 1 of 24 Workforce and OD

2 computer accessibility. There is no dedicated time for staff to undertake this training and computer accessibility is variable. In particular ward based computers are needed for access to clinical portals and other urgent needs which restricts their availability for training purposes. E - Learning training covers general fire safety subjects, therefore additional area specific training is necessary for staff working in higher fire life risk areas. Post Induction there is no monitoring of this secondary local training. The South Wales Fire Service is undertaking unannounced visits to ward areas within the Health Board. Notably these audits have been undertaken in other Health Boards in Wales and even those with very high compliance levels to mandatory training have reported poor A pilot of Ward based briefings by the Senior Fire Adviser resulted in these areas being considered as being of very high compliance by the South Wales The objectives of these changes are to provide easier access to training, making it more flexible and relevant to each workplace, resulting in increased numbers of staff completing training. It is suggested that a dual approach of greater accountability and a review of training approaches be adopted. Appendix 1 contains a summary of proposed actions to address the above failings with regard to Induction and Mandatory Training Learning Education and Development are to pilot alternative learning approaches to supplement the E learning Until alternatives agreed Fire Induction will be offered as a tutor led course ran Uptake of Mandatory Training page 2 of 24 Workforce and OD

3 Action/Decision required Link to other Board (s) and subcommittees Link to Standards for Health Services in Wales monthly. Appendix 2 contains a summary to mandatory fire training and proposed frequencies of refresher, offering a more flexible approach and based off a pilot,high level of fire knowledge Ward based Staff account for one third of the annual fire training requirement Ward managers and Staff will be trained on their local arrangements by the Fire Safety Department and they then will be allowed to cascade this information to those staff that was not present or haven t undertaken the E learning course during the year. The above training will be approximately half the duration of the current programme Non compliance to Fire Training will be more closely monitored by the Fire Safety Group, Chaired by Executive lead for Fire land regular assurances shall be considered by the Health and Safety It is also proposed that a review of the training packages and the staff should not be allowed to undertake other professional development until they completed their mandatory training To approve the proposed approaches and actions To consider mechanisms to ensure implementation of the actions Health & Safety Operational Group Violence and Aggression Action Plan Implementation Group New Standard 6: Managing Risk and Health and Safety Uptake of Mandatory Training page 3 of 24 Workforce and OD

4 Link to Public Health Agenda Link to UHB Strategic Direction and Corporate Objectives / Legislative and Regulatory Framework Core objective for the Board in relation to Health and Safety of its employees. Health & Safety at Work Act 1974, Management of Health and Safety at Work Regulations 1999, The Regulatory Reform (Fire Safety) Order 2005 (RRO) Link to relevant evidence base REPORT ON THE UPTAKE OF MANDATORY AND INDUCTION TRAINING OF FIRE AND THE ACTIONS TO IMPROVE COMPLIANCE RATES WITHIN THE UHB INTRODUCTION At the January meeting of the Health and Safety concern was expressed at the low level of Mandatory Training compliance and in particular fire training. The Chief Executive requested that the Issue be referred to the Workforce and Organisational Development in order to develop a plan to significantly increase compliance for fire and other safety training. The Health Board has a statutory obligation to undertake both Induction and Mandatory training. In the case of fire training, failure to give sufficient information to staff is not simply a breach of our statutory duties but is placing both patients and staff at significant risk of serious injury or death. Corporate Manslaughter laws clearly apply where there are serious management failures resulting in a gross breach of a duty of care. BACKGROUND In October 2007 the previous Cardiff and Vale NHS Trust moved from tutor led mandatory training to the current e-learning approach. The aim Uptake of Mandatory Training page 4 of 24 Workforce and OD

5 was to provide cost effective learning activities to address the increasing demand and to allow for departments to achieve compliance in the most convenient means to them i.e. releasing staff for computer time rather than dedicated training sessions away from the workplace. Compliance levels at that time were reported at 40% for mandatory training and 71% for fire induction Induction E Learning is undertaken utilising a nationally developed package whilst Mandatory Training E learning programme was developed internally CURRENT COMPLIANCE STATUS Fire Mandatory Training Division Children & Women 23% Clinical Diagnostics 21% Dental 28% Finance 11% Governance 17% Medicine 19% Mental Health 17% Nursing (inc Operational Services) 8% Primary, Community, Intermediate Care 20% Specialist Services 18% Surgical 19% Therapies & Health Science 31% Workforce & OD 8% UHB Average 19% Apr- Nov percentage compliance Total number of Staff identified as requiring training was and total number trained 2811 The above data shows compliance levels at only 19% for Mandatory Fire for the UHB as a whole, with some areas being in single figure percentage(april-november 2010). Previous estimates suggest that there are 4800 ward based staff. Uptake of Mandatory Training page 5 of 24 Workforce and OD

6 Compliance in the non ward based services is lower than clinical areas. Induction training status for the last quarter of 2010/11 was at 22 % for modules, 46% for the year as a whole.this is amongst the lowest in Wales. Although the latter is currently being validated for Fire it is unlikely to be significantly amended Current Monitoring Requirements On recruitment, the Manager/inducting officers are required the initiate the Local Induction Check list protocol with a goal of achieving excellence in providing safe, effective,efficient and compassionate care and meeting the organisation s statutory obligations. This requires the manager to ensure that: All employees receive a departmental (local) induction on the first day of employment with both manager and employee signing each section. The Corporate Induction programme should be completed in eight weeks Once completed the checklist is placed on the employee s personal file Ensure access and complete E learning corporate induction programme or attendance to Induction training course. Point out the location of fire exits and emergency numbers Point out the location of fire evacuation assembly points Explain the fire procedures and different types of alarms The Learning, Education and Development Department receive details of all new starters from Recruitment. Where the Corporate Induction programme has not been completed within the 8 weeks period a reminder is sent by the Department, which is repeated if the first reminder is not acted upon. Compliance is monitored through the Learning and Education Department and is reported at the Workforce and Organisational Development and Health and Safety. Accountability for failing to comply is therefore held at Divisional level With regard to Mandatory training, all U.H.B. staff are required to complete Fire Safety E - Learning Mandatory Training on an annual basis. Access to E - Learning is via Learning Education and Development (previously known as OD&T). Any staff that are unable to Uptake of Mandatory Training page 6 of 24 Workforce and OD

7 reach the pass mark are required to undertake individual training covering subjects where they are experiencing difficulties, and this will be provided locally by the Area Manager/Fire Warden Identified Deficiencies As stated the current mechanisms for undertaking Mandatory Training are mainly via e-learning with a small number of tutor led sessions being delivered in areas where there is limited computer accessibility. There is no dedicated time for staff to undertake this training and computer accessibility is variable. In particular ward based computers are needed for access to clinical portals and other urgent needs which restricts their availability for training purposes. The consistent response with regards to the low level of compliance from local areas is that due to staffing shortages, staff cannot be released for either dedicated computer time or tutor led courses. Also Staff reported difficulties due to both speed of the network/ computers and the complexity of the package used. The programme is too long- it involves at least 8 hours of computer time. Whilst the package does allow the training to be completed in modules it still represents a significant commitment and ties up ward based computers. E learning packages were developed from the previous tutor led sessions and as such may include information that is interesting but not essential to the member of staff e.g. because most Mandatory training is established to meet statutory obligations it contain the outline of the legislative justification and requirements. To the employee justification is not necessary, given that has been mandated. Whilst the above issues are relevant, they cannot fully explain why compliance levels in other training subject areas are higher or why other Health Boards in Wales with similar staffing and financial restraints as Cardiff and Vale, report much higher compliance status levels. In discussion areas often refer to their compliance in comparison to the Heath Board average.this is potentially inferring that providing as an area they are not the least compliant, their status is acceptable for example; four years ago an area showing 30% compliance would be considered as a poor performer, whilst currently they may be considered the highest achievers. In fact, both are totally unacceptable Uptake of Mandatory Training page 7 of 24 Workforce and OD

8 From the prospective of information and instruction, developing training through E learning offers an easy solution for the trainer to meet their obligation on compliance, passing the responsibility to the line manager for completing the action. This however has resulted in a proliferation in the number of E learning packages available to staff and leaves the local managers confused as to what is essential and what is desirable. It is essential to note that the E - Learning training covers general fire safety subjects, therefore additional area specific training is necessary for staff working in higher fire life risk areas. Post Induction there is no monitoring of this secondary local training. FIRE AUDITS The South Wales Fire Service is undertaking unannounced visits to ward areas within the Health Board. A key requirement of the audit is to interview staff and verifies if they have received training and are aware of the fire local evacuation process. Notably these audits have been undertaken in other Health Boards in Wales and even those with very high compliance levels to mandatory training have reported poor performance to these criteria. Internal visits by the Fire officers confirm similar finding with the UHB A pilot of Ward based briefings by the Senior Fire Adviser has been undertaken over the past 3 months to staff within the Children s Hospital wards. These areas have been visited by the South Wales Fire Service, who considered compliance to training knowledge to be very high PROPOSAL FOR IMPROVING COMPLIANCE The objectives of these changes are to provide easier access to training, making it more flexible and relevant to each workplace, resulting in increased numbers of staff completing training. It is suggested that a dual approach of greater accountability and a review of training approaches be adopted. Induction Training Learning Education and Development are to pilot alternative learning approaches to supplement the E learning. A meeting of the Training providers is set for mid May Uptake of Mandatory Training page 8 of 24 Workforce and OD

9 Consideration was given to running Formal Tutor led sessions and dedicated computer time for all new recruits at the Training Department. However, restrictions in the number of computers available within the this department means that a maximum of 12 people would be able undertake the sessions at any one time and hence a one day training induction course ( 2 half day sessions) would have a maximum attendance of 24. Even with the current level of restricted recruitment, Based off 2010/11 where a total of 994 new staff were recruited, and assuming maximum capacity at each session, this will require 42 Induction training days. This would mean that these training sessions would have to occur on a weekly basis for full compliance to be achieved. This is a significant commitment and demand on the tutors and resources. Equally mechanisms will need to include ensuring staff are released for these sessions. The local managers are required to complete an induction check list for all new recruits who include a statement in relation to local fire arrangements. This should be enhanced to a more detailed sheet which should include: Understanding fire alarm sounds, in the immediate and surrounding areas (continuous and intermittent sounds); Understanding evacuation procedures for different areas and premises; How to understand the information displayed on the fire alarm indicator panel; How staff should react if a fire occurs in various locations within the area; The Telephone alert number and isolation needs A copy of this record should be kept by the local manager and sent to the Fire Safety Department. Uptake of Mandatory Training page 9 of 24 Workforce and OD

10 Appendix 1 contains a summary of proposed actions to address the above failings with regard to Induction. Mandatory Fire Training It can be seen from the above that the current mechanism for ensuring staff are appropriately competent in Fire is failing. Staff are either failing to access training sessions or the instruction they receive is insufficient. A more flexible approach will be adopted which should help Managers to meet their staff training requirement. Moving the emphasis from the centralised training the member of Staff to Training the ward manager and allowing them to cascade the knowledge down to their staff. It should be noted that this will run along side the E learning hence managers can opt to continue current methods if preferred To support the Fire Safety Advisers will prepare specialised training/briefing for each area, these will be approximately 20mins in duration Ward based Staff account for one third of the annual fire training requirement Ward managers will be trained on the key elements on their local arrangements and they will be required to cascade this information to staff. Annual or two yearly workplace visit with a Fire Safety Advisor Appendix 2 contains a summary of training frequency and approach for groups of staff The Fire Safety Advisor has the option to attend where smaller numbers may be present e.g. for a small high risk department when the Area Manger or Fire warden also attends. Thereafter, the Area Manager/Fire Warden will be for passing the training on to remaining staff. In order to assist with this, a workplace visit training note will be provided by the Fire Safety Advisor. Where Ward managers have completed the ward based training e- learning can be extended from one to two years, however this will require verification by the fire adviser Uptake of Mandatory Training page 10 of 24 Workforce and OD

11 Local training days/combined fire safety training sessions FOR DECISION In cases where Area Managers organise local training days (i.e. when various speakers attend) or combined fire safety training sessions for more than one ward or department, Fire Safety Advisors will continue to attend where possible. Local training days or combined fire safety training sessions must be attended by at least 12 staff per session. In the event of any changes which reduce attendance below the minimum, the area manager must inform the Fire Safety Advisor immediately so that the session can be rearranged. For certain categories of staff, e.g. where there may be difficulty in accessing or using a computer, training may be delivered via an annual teaching session with a Fire Safety Advisor (see Appendix 2 below). Thereafter, the Area Manager/Fire Warden will be responsible for passing the training on to remaining staff. 4. RECORDING TRAINING The Area Manager/Fire Warden must keep records of fire safety training which should include details of: E - Learning training completed; individual training given by the Area Manager/Fire Warden, with staff who are unable to reach the E - Learning training pass mark; Workplace visit training with a Fire Safety Advisor (or equivalent training as above). The Area Manager/Fire Warden will be responsible for notifying Organisational Development and Training (now Learning Education and Development) when staff completes fire safety training. Keeping up to date training records is a legal requirement and will be inspected by visiting internal Fire Advisers and Officers from South Wales Fire and Rescue Service. Appendix 1 contains a summary of proposed actions to address the above failings with regard to Mandatory Training Uptake of Mandatory Training page 11 of 24 Workforce and OD

12 CONCLUSION The report summaries current status and proposed actions to improve compliance to both Induction and Mandatory refresher Fire Training It recognises that although the level of fire training has reduced a number of pilots and approaches are under consideration to improve both the quantity and the quality of the training RECOMMENDATION The is asked to: NOTE the report and SUPPORT the proposed actions identified in appendix 1 IMPACT ASSESSMENT Health Improvement Linked to Corporate Health Standard Workforce Financial Legal Equality Environmental Duty of Care to our Staff Potential financial issues if we do not comply with regulatory requirements or fail to at appropriately to protect people and property in the event of a fire The UHB has a responsibility under the Health and Safety at Work Act and the Regulatory Reform (Fire Safety) Order 2005to reduce the risks of fire to the lowest reasonable practicable level. Equality Act has been considered No impact assessed. RISK ASSESSMENT Clinical/Service Financial Reputational Provides for a safer patient environment There are no direct financial consequences for the UHB. Reduces the potential of negative publicity for fire incidents Uptake of Mandatory Training page 12 of 24 Workforce and OD

13 CONSULTATION AND ENGAGEMENT Not applicable. SOURCES OF INFORMATION & EVIDENCE Information retrieved from Datix Incident database and ESR training database. Fire Report submitted to January Health & Safety V&A Induction Training Statistics submitted to WAG DATA Group Induction Check list Uptake of Mandatory Training page 13 of 24 Workforce and OD

14 Appendix 1 Proposed Actions to improve Fire Training Compliance Item Current Failure Proposal Departmental Responsibility 1 Induction offered mainly has E learning programme Staff failure to receive induction training Alternative approaches to delivering induction compliance to be developed by LED Until alternatives agreed Fire Induction will be offered as a tutor led course ran monthly. Learning Education and Development Learning Education and Development Lead Responsibility Ast Director Workforce Ast Director Workforce Assurance Workforce OD The Fire Safety Department will receive information from ODT of all staff on recruitment broken down by both geographic area and department Fire Safety Department will be sent details of all new recruits who has not completed the fire E learning module within the 8 weeks Learning Education and Development Ast Director Workforce Manager to be mandated to send those staff on next available course Human Resources Director of Planning/ Workforce OD Director Workforce OD Fire Safety Adviser to visit area to confirm compliance Fire Safety Department Senior Fire Adviser Fire Safety Group /Health and Uptake of Mandatory Training page 14 of 24 Workforce and OD

15 Failures found by Fire Safety Adviser will be reported to the Fire Safety Group and the Executive Lead for Fire Safety Local Nominated officer Fire to explain failure at Fire Safety Group Divisional Fire Safety Manager Health and Safety. 2 Completion of Local Induction Check list held within personal file Lack of assurance that local Fire induction has been undertaken Local induction procedures to be amended to require the senior person to confirm that they have informed the new recruit of all their local arrangements broken down by key component areas. Learning Education and Development Ast Director Workforce Workforce OD A copy of this report will not only be kept in the personal file but will be sent to the Fire Safety Dept. Local Department Ward Manager Compliance to induction training will be monitored at the Fire Safety Group and the Fire Officer will progress all employees for whom they have not received confirmation of completion Fire Safety Department Senior fire Adviser Health and Safety. 3 Induction E Learning Programme takes Staff Report difficulty in releasing staff and computer IMT advice to be sort about means of speeding up programme. Organisation to initiate discussion with All Wales training managers Learning Education and Development Ast Director Workforce Health and Safety Uptake of Mandatory Training page 15 of 24 Workforce and OD

16 estimated 8 hours to complete 4 Mandatory Training is centrally aimed at individual staff members availability of length of time The organisation has consistently failed to meet it mandatory training requirement to consider contents and reducing completion time Fire Safety Department will develop ward based briefings and train ward managers to deliver the sessions for cascading to their staff Fire Officers will support managers by offering tutor led sessions at the ward area for ward managers and will visit the ward at least on an annual basis to verify that this cascade training has been undertaken Fire Safety Department Fire Safety Department Senior fire Adviser Senior fire Adviser Health and Safety 5 Mandatory Training for Fire is repeated annually Where ward based staff have received this local training formal mandatory training can be deferred to a 2 yearly rather than annual basis. This will be verified as part of at least an annual visit by Fire Safety Dept. Local Department Fire Safety Department Ward Manager Senior fire Adviser Health and Safety Health and Safety 6 E learning courses are available within the HB network for Staff report confusion of what is mandatory A review of the current e-learning courses available be initiated and a matrix of those which are mandatory and those which are based of assessment be Learning Education and Development Ast Director Workforce Workforce OD Uptake of Mandatory Training page 16 of 24 Workforce and OD

17 both Mandatory and other training requirements 7 Mandatory E Learning Programme takes estimated 8 hours to complete 8 Performance appraisal 9 Staff may undertake personal and professional development along side the Mandatory Training Staff Report difficulty in releasing staff and computer availability of length of time Mandatory Training is of the highest importance Staff may be released for non essential training without having completed distributed, A review of the mandatory training packages to diminish the time taken to complete the programme be undertaken by the various leads PDR s must include the persons mandatory training status and where they have managerial responsibility for staff their groups overall compliance standing Staff should not be allowed to undertake any development training until they have completed induction and all their mandatory training elements Study Leave forms to include managers and individual to confirm that mandatory training completed prior to approval Learning Education and Development Human Resources Human Resources Ast Director Workforce Ast Director Workforce Ast Director Workforce Workforce OD Workforce OD Workforce OD Uptake of Mandatory Training page 17 of 24 Workforce and OD

18 Cardiff and Vale U.H.B. Fire Safety Department Proposed Fire Safety Training methods and frequencies with effect from 1 st April 2011 CATEGORY OF STAFF All new employees joining Cardiff and Vale U.H.B. Ward based nursing staff. Includes all Mental Health and specialised wards such as: Intensive Therapy Units; High Dependency Units; Cystic Fibrosis Units. ADDITIONAL INFORMATION Face to face Induction Training at the Learning Education and Development Centre, Whitchurch Hospital. Staff working mainly within these areas, but not in direct patient care should receive the same training as those who do work in direct patient care. Examples are: Therapists; Administrative Staff. E - LEARNING WORKPLACE VISIT BY FIRE ADVISOR ANNUAL ANNUAL 2 YEARS May be extended to 2yearly if Ward Manager verifies that they have cascaded training down to Staff during intermediate Uptake of Mandatory Training page 18 of 24 Workforce and OD

19 CATEGORY OF STAFF Theatre based nursing staff, Including: Main Theatres; Day Surgery Theatres; Other Theatres areas such as recovery rooms. ADDITIONAL INFORMATION Staff working mainly within these areas, but not in direct patient care should receive the same training as those who do work in direct patient care. Examples are: Therapists; Administrative Staff. E - WORKPLACE VISIT BY LEARNING FIRE ADVISOR ANNUAL ANNUAL 2 YEARS Housing in the community staff. N.B. Sleeping risks. Examples are: Professional and technical staff working in laboratories/areas where larger amounts of flammable liquids and gases are stored/used. Security and Portering staff. Histopathology and Toxicology laboratories. OPTION: Training may be delivered via an annual teaching session with a Fire Safety Uptake of Mandatory Training page 19 of 24 Workforce and OD

20 Hospital reception and switchboard staff. Advisor. OPTION: Training may be delivered via an annual teaching session with a Fire Safety Advisor. CATEGORY OF STAFF Catering and housekeeping staff -Including staff working in main kitchens. Nursing staff in general areas examples are: Outpatients; Day Care Centres; X - Ray Departments and associated Scanning Departments; ADDITIONAL INFORMATION OPTION: Training may be delivered via an annual teaching session with a Fire Safety Advisor. Staff working mainly within these areas, but not in direct patient care should receive the same training as those who do work in direct patient care. Examples are: Therapists; Administrative Staff. E - WORKPLACE VISIT BY LEARNING FIRE ADVISOR ANNUAL ANNUAL 2 YEARS Uptake of Mandatory Training page 20 of 24 Workforce and OD

21 Endoscopy Departments. Therapists working mainly within Therapy Outpatients Departments. Examples are: Physiotherapists; Occupational Therapists; Dieticians. CATEGORY OF STAFF ADDITIONAL INFORMATION E - WORKPLACE VISIT BY LEARNING FIRE ADVISOR ANNUAL ANNUAL 2 YEARS Health Centre and Clinic staff working in community premises. Professional and Technical Staff working in laboratories/areas where smaller amounts of flammable liquids and gases are stored/used. Examples are: Biochemistry and Cytology laboratories; Pharmacies. Uptake of Mandatory Training page 21 of 24 Workforce and OD

22 Estates Management staff. Additional annual training to be provided by Estates managers, covering: Estates staff roles in the event of a fire situation; Updates regarding initial response; Post incident Estates procedures. FOR DECISION CATEGORY OF STAFF ADDITIONAL INFORMATION E - LEARNING WORKPLACE VISIT BY FIRE ADVISOR ANNUAL ANNUAL 2 YEARS Doctors. All grades and categories. Doctor Medical Students. All Doctor Medical Students. Uptake of Mandatory Training page 22 of 24 Workforce and OD

23 Administrative staff working in office based premises within main hospital sites, which are not located within direct patient care areas such as wards, theatres. Young persons (between the ages of years) e.g. apprentices, or persons on work experience. Young persons must be closely supervised, particularly during fire emergencies as their ability to perceive and react to risk may not be fully developed. Attendance at a training session to be given by a Trust Fire Safety Adviser before attending the workplace i.e. Face to face Induction Training at the Learning Education and Development Centre, Whitchurch Hospital. This must be followed up by additional site specific training given by the Area Manager/Fire Warden on the first day of attending the workplace. Thereafter, training is to be arranged in accordance with the individuals category of staff above. CATEGORY OF STAFF ADDITIONAL INFORMATION E - WORKPLACE VISIT BY Uptake of Mandatory Training page 23 of 24 Workforce and OD

24 All contractors working within U.H.B. sites. The U.H.B. uses approved contractors who are responsible for training their staff in generic fire safety procedures. U.H.B. control measures include: Permits to work; Hot work permit; Site monitoring of fire safety standards; Major contracts liaison with Trust Fire Safety Advisors before and during major works. FOR DECISION LEARNING FIRE ADVISOR ANNUAL ANNUAL 2 YEARS Uptake of Mandatory Training page 24 of 24 Workforce and OD