BOARD OF DIRECTORS 13 th July 2016

Transcription

1 BOARD OF DIRECTORS 13 th July 2016 Item Ref No: 12 TITLE OF PAPER Mandatory Training Compliance Improvement TO BE PRESENTED BY Dean Wilson, Associate Director of Human Resources ACTION REQUIRED For information and discussion. OUTCOME To be noted at Trust Board. TIMETABLE FOR DECISION N/A LINKS TO OTHER KEY REPORTS / DECISIONS LINKS TO OTHER RELEVANT FRAMEWORKS BAF, RISK, OUTCOMES ETC NHS Constitution: Patients Public Staff HSE MH Act Equality Act 2010 IMPLICATIONS FOR SERVICE DELIVERY AND FINANCIAL IMPACT Additional staff release for Training required in order to meet Targets CONSIDERATION OF LEGAL ISSUES Some Mandatory Training subjects are a statutory requirement Author of Report Designation Date of Report Guy Hollingsworth HR and Workforce Key Projects Lead 4 th July 2016

2 Report to: Board of Directors Date: 13 th July 2016 Subject: From: Author: 1 Purpose For Approval SUMMARY REPORT Mandatory Training Compliance Improvement Dean Wilson, Director of Human Resources Guy Hollingsworth, HR and Workforce Key Projects Lead For a collective decision To report progress To seek input from For information Other (please state below) To update Board on Mandatory Training Developments and in particular the issuing of a Contract Compliance Notice by the CCG and the requirements for a planned trajectory over the next 12 months to meet targets. 2 Summary Sheffield CCG has issued the Trust with a contract performance notice in respect of improving mandatory training compliance. On the basis of the initial communication from CCG, improvement targets have been set for four of the Clinical Directorates in relation to the subjects identified by the CCG as priority. These were: Basic Life Support Immediate Life Support Clinical Risk Assessment and Management Mental Capacity Act DOLS Medicines Management Rapid Tranquilisation Safeguarding The Trust has chosen to add Respect Level 2 and 3 to that list. An initial trajectory plan has been developed. This sets Directorate targets to meet the 80% target for most subjects by March 2017 and for the remaining by June Attached to this summary report is the report to EDG dated 23 rd June that has also been tabled at Workforce and OD Committee. A further discussion at EDG will be held on 7 th July. The Trajectory plan will be revised further to include the following Targets to be set on a monthly basis Targets to be set for Primary Care and Corporate Directorates Updated to take account of the Q1 Compliance Report (as at 30 th June) The Trajectory plan will then be shared with Sheffield CCG in July. There will then be a further update in October based on Q2 compliance figures and any feedback from CCG. Attached to this front sheet are Item: 12 Appendix 1 Appendix 2 Appendix 3 Summary Report to EDG 23 rd June Report to EDG and WODC 23 rd June Draft Directorate Targets as at 23 rd June (to be further updated)

3 Appendix 4 Mandatory Training Compliance Report for Quarter Next Steps Improving staff release and attendance at Training is now critical. Mandatory Training Compliance has been set as a high priority within Team and Directorate Governance. Monthly reports will be developed ass soon as the resource is available (October at the latest) Additional Training is required for some subjects. These are either now in place (Mental Capacity Act Level 2) or are being planned for increased delivery from August (eg Medicine Management, Rapid Tranquilisation). Additional resources are being provided to the Respect Training Team Some subjects are new (eg Autism Awareness from April) and e Learning is being rolled out Additional e learning has been developed for some subjects (eg Basic Life Support) The Trust has issued an all staff leaflet in relation to Deprivation of Liberty Safeguards Level 1 as e learning has not been available recently due to case law changes 4 Required Actions Key actions are as follows Ensuring that sufficient training is provided to enable targets to be met (Responsibility of the Mandatory Training Steering Group) Continuing to provide accurate quarterly reports on Mandatory Training Compliance and moving to monthly reports as soon as possible (Responsibility of the Mandatory Training Steering Group) Ensuring that staff are booked on and released to attend training in order to maintain training compliance (Responsibility of Directorates) 5 Monitoring Arrangements Via (Responsibility of the Mandatory Training Steering Group) And regular reports to EDG. 6 Contact Details For further information, please contact: Guy Hollingsworth HR and WorkForce Key Projects Lead Guy.hollingsworth@shsc.nhs.uk. Tel

4 Report to: Executive Directors Group SUMMARY REPORT Open BoD 13 th July 2016 Item 12 Appendix 1 Date: 23 rd June 2016 Subject: From: Mandatory Training Compliance Trajectory Guy Hollingsworth 1 Purpose For Approval x For a collective decision To report progress x To seek input from x For information Other (please state below) 2 Summary Sheffield CCG have issued a Contract Performance Notice in respect of the Trust s levels of Mandatory Training Compliance. The Trust is required to provide a trajectory for improving compliance. The attached report describes in more detail the steps taken to develop a trajectory for improved compliance and the issues this raises. The report includes an appendix that provides a quarterly beak down for each Directorate that sets out the trajectory towards an 80% target for each of the subjects understood to be on the CCG list. The letter received from the CCG at the end of last week seem to contain a different list of priority subjects and a brought forward timescale for the above work. This requires clarification. 3 Next Steps Targets still to be set for Non Clinical Directorates and for Primary Care Targets to be refined further after Quarter 1 Reports Targets to be developed for other subjects as required Actions to be taken as outlined above for those subjects requiring increased delivery 4 Required Actions Advice from EDG as to whether this is the correct approach overall Targets have been set to be very challenging (esp from Sept 16). Advice from EDG as to the timescales finally agreed with CCG and the process for reporting to them

5 Advice from EDG as to whether monthly targets are required rather than quarterly ones. Advice from EDG on any other subjects to be covered Advice from EDG as to whether this report (with this section amended) can go forward to WODC. Mandatory Training is an item for the July meeting. 5 Monitoring Arrangements Further Report to EDG on 7 th or 14 th July after Quarter 1 reports and refined trajectory 6 Contact Details Guy Hollingsworth

6 Appendix 2 Report to EDG Mandatory Training Trajectory 1. Introduction Sheffield CCG has issued the Trust with a contract performance notice in respect of improving mandatory training compliance. On the basis of the initial communication from CCG, Guy Hollingsworth and Jennie Wilson have met with the four Clinical Directorates to identify planned trajectory for mandatory training compliance improvement in relation to the subjects identified by the CCG as priority. These were: Basic Life Support Immediate Life Support Clinical Risk Assessment and Management DOLS Medicines Management Rapid Tranquilisation Safeguarding The Trust has chosen to add Respect Level 2 and 3 to that list. The first Draft of Quarterly Targets for the above subjects are included as Appendix 1. These will require further refinement based on; More detailed analysis of the training shortfall after Quarter 1 reports. Quarter 1 reports will include further updates to the Training Competency Requirements which will alter some figures. The Q1 Reports will also have more information that enables us to distinguish between staff who have had no training and staff who are out of date. This is relevant for some subjects where the initial training is a lengthier package than the repeat training. More work on increasing training provision for subjects where there is currently a shortfall. The planning of and timescales for additional training is part of the process for detailed trajectory planning 2. Compliance Improvement Targets These have been developed on a quarterly basis and on the basis of what were understood to have been the CCG s priority subjects. However the CCG letter has now arrived. It has a different priority list. It also requires monthly targets and for all subjects not just the priority ones. Subsequent to this report, the author will develop projection targets for the other priority subjects and share these with Directorates. The attached table (Appendix One) lays out compliance targets for each of the subjects we initially understood to be on the CCG priority list per Directorate. They have been developed on quarterly basis as this seemed the most sensible way to plan for improvement as the frequency of training is not always completely consistent over every month. Work has not yet been undertaken for Non-Clinical Directorates and for the Primary Care Directorate. This table shows that with a few exceptions the Trust should reach an 80% target for all subjects by March It is not straight forward to provide precise numbers for each subject as staff who are currently up to date with a subject will drop out once their expiry date passes and this will be a variable. Those subjects where the trajectory does not reach 80% by March 2017 are as follows:

7 Respect Level 2 Inpatient Directorate. 80% to be achieved by June The rationale: The requirement to also meet targets for Respect Level 3 and the relatively high level of turnover in the Directorate. Initial Training for Respect Level 3 and 2 is considerably more time consuming than for other subjects. Class sizes for Respect Level 3 and 2 have to be very small and high trainer numbers are required. As highlighted in the last report to EDG an additional Band 4 Respect Trainer is required to enable sufficiently delivered. Respect Level 3 requires refresher training every year. MCA Level 1 and MCA Level 2 - Inpatient Directorate. 80% by June Very low level of current compliance due to reduced availability of training. Plans are in place to address this. The Inpatient Directorate has the heaviest per staff member training load. MCA Level 1 Communities, MCA Level 2 Communities and Specialist. Again the target for these subjects is to reach 80% by June This is because of the large number of staff requiring the training and the relatively low starting base. We also have to be mindful that renewal training will be required in three years time. Whilst some of this may be by e-assessment, this may be limited by the fact that MCA and DOLS are likely to be subject to changing legislation and guidance over the next three year period requiring further face to face training. Respect Level 1 Communities and Specialist. The current resources of the Respect Training Team are fully absorbed in the training plan for Levels 3 and 2 (In patient and other bed based services). Respect Level 1 is required for Community services. The plan is to recruit 6 trainers each from Community Directorate and Specialist Directorate and train them as Trainers in order to roll out a Respect Level 1 programme over the next 2 years. Staff in Corporate areas will require Respect Basic Awareness but this will not involve the reaching of any breakaway techniques and so can be delivered by e Learning (once a package is identified). 3. Subject Issues DOLS There have been problems over the last twelve months with the availability of elearning training for DOLS Level 1. This is due to the fact that case law changes have a major impact on national guidance. Although we are working to bring some elearning back for availability, the decision was taken through the MCA group and the Mandatory Training Steering Group to meet the level 1 target on an interim basis with an all staff leaflet. This will be disseminated in late June / early July to all staff and by hard copies via Directorates by the end of the month. The view from the MCA group and the Mandatory Training Steering Group is that this will meet our compliance on an initial basis but that we should then restart elearning once this is available via our electronic system for new starters and for refresh training when required in three years time. We will need to decide how to report on this training as a compliance percentage in the interim DOLS Level 2 this is required for a smaller number of staff. This is provided by the Local Authority. Discussions are in place with the Local Authority to ask them to increase the volume of training as this will be required to meet the target. MCA Subsequent communication from the CCG has provided a different list of priorities subjects. Some of the above are missing and MCA has been added. Therefore this report

8 includes targets for MCA compliance although it was not possible to discuss these with all directorates since MCA was not on the list at the time. MCA Level 1 is available by elearning and Workbooks and work has been ongoing in Learning Disability and Specialist Directorates to improve compliance. MCA Level 2 training has not been available until recently. However the Trust is funding a trainer to provide weekly courses in order to improve compliance. Sufficient training should be available. There may be issues of release that raise questions as to whether we need to provide some training after March Training is valid for a three year period. We will need to have a refresh plan in three years time. This could be via e- Assessment. However training will be required for any staff who fail the e-assessments. BLS/ILS The Trust is looking at buying in additional support to increase the level of training provision for these courses. The longer term plan is to have additional training resource by the appointment of a Resuscitation Officer. Medicines Management and Rapid Tranquilisation These are training sessions provided by the Pharmacy department. Medicines Management is required for all registered nurses. Rapid Tranquilisation is required for Inpatient nurses and doctors. These subjects represent the greatest challenge in terms of current low compliance and limited availability of training. Discussions are ongoing with the Pharmacy department about the need to provide substantially high levels of training in the short term (next six months). The medium term plan is to move elearning/e- Assessment for repeat training. Safeguarding Training is available in sufficient quantities. The task is to ensure that staff attend. The CCG have not specified Safeguarding Adults or Safeguarding Children. Training is provided in one day that incorporates Safeguarding Adults Level 2, Safeguarding Children Level 2 and 3, Domestic Abuse, Prevent, Childhood Sexual Exploitation. However, although going forward, attendance at training will improve compliance equally on all subjects because this comprehensive training has not been in place for three years, the compliance percentages remain different across the different subjects included within the training. It would not be cost effective to provide sessions simply to provide catch up on individual subjects. It is therefore recommended that the Trust set targets in relation to Safeguarding Adults. Improvement in those targets will bring up training levels for Safeguarding Children. However some of these other Safeguarding subjects will remain below 80% in the short to medium term. This is because of changes in training provision and of who requires which types of training that have taken place within the last three years. It is recommended that Services, where Safeguarding Children percentages are below 80%, are required to satisfy themselves that there is sufficient training levels in each of the team to provide the expertise required. The level of training provided by the comprehensive safeguarding training day will mean that compliance will reach 80% but will not do so as quickly for Safeguarding Children as it will for Safeguarding Adults. 4. Quarter One 2016/17 Reports and Future Reports The plan is to produce these by end of the first week of July if at all possible. In order to do this they will be based on training completed as at 17 June rather than 30 th. Considerable work has taken place between April and June in further clarification of the training competency requirements for different subjects and different staff. This means that there will be some changes in compliance percentages arising not necessarily from training undertaken but from changes to staff numbers requiring. More close attention has been paid to ensuring that staff are identified as mandatory only where this is essential. There has also been work done in improving data collection in relation to training elsewhere (eg Medical CPD, work completed on MCA Workbooks etc).

9 These next Quarterly reports will also provide a percentage figures for staff who have completed training but are less than 6 months out of date as well as distinguishing between staff who have not had any training at all and those who are out of date. Recruitment is now set to take place to ETD admin posts. Agreement has been reached with staff side on the consultation process for changing of job roles and this has enabled recruitment to commence. As soon as staff are appointed then they will receive training on OLM and the process for developing Mandatory Training Compliance reports. The plan is for ETD admin to take over the production of Quarterly reports from Q2 (as at end of September) and then produce on a monthly basis. 5. Required Actions and Next Steps Advice from EDG as to whether this is the correct approach overall. Targets have been set to be very challenging (esp from Sept 16). EDG Decision (23 rd June) to support the plan to set challenging targets Advice from EDG as to the timescales finally agreed with CCG EDG Decision (23 rd June): Report and Trajectory plan to be submitted to CCG in mid July and further refined in October after Quarter 2 reports Advice from EDG as to whether monthly targets are required rather than quarterly ones. EDG Decision (23 rd June) Targets to be broken down into monthly targets. Reports on progress will include a breakdown by Directorate and be provided quarterly (Quarter 1 and Quarter 2). We hope to be able to provide monthly reports once we have sufficiently staff in ETD admin team trained for the task and are able to provide monthly reports internally. The aim for this is Oct 16 Advice from EDG on any other subjects to be covered EDG Decision (23 rd June): The initial Trajectory to be based on those subjects previously identified by the CCG as a priority and already included in the draft trajectory. Targets for the remaining subjects on the Core 20 Mandatory Training subjects list (Appendix 2) to be included after end of Quarter 2 Advice from EDG as to whether this report (with this section amended) can go forward to WODC. Mandatory Training is an item for the July meeting. EDG Decision (23 rd June): Yes, including the EDG discussions outlined above Targets still to be set for Non Clinical Directorates and for Primary Care. To be included in the revised draft of the Trajectory to be finalised by mid July (after Quarter 1 reports) Targets to be refined further after Quarter 1 Reports Actions to be taken as outlined above for those subjects requiring increased delivery Guy Hollingsworth 20 th June 16 revised 23 rd June 16

10 Directorate Targets for Mandatory Training Compliance APPENDIX 3 Subject and Directorate Current Compliance Target Sep 16 Target Dec 16 Target Mar 17 BLS In-Patient Directorate 58% 60% 80% Learning Disability Directorate 69% 80% Communities Directorate 30% 40% 60% 80% Specialist Directorate 52% 65% bed based services 80% bed based services 80% all teams ILS In-Patient Directorate 51% 60% 70% 80% Learning Disability Directorate 33% 60% 80% Communities Directorate 9% 30% 60% 80% Specialist Directorate 49% 60% 80% Clinical Risk Assessment and Mgt In-Patient Directorate 56% 65% 80% Learning Disability Directorate 50% 80% Communities Directorate 51% 60% 80% Specialist Directorate 38% 50% 65% 80% DOLS Level 2 In-Patient Directorate 18% 25% 60% 80% Learning Disability Directorate 0% 30% 80% Communities Directorate N/A N/A N/A N/A Specialist Directorate 4% 40% 65% 80% Medicines Management In-Patient Directorate 35% 40% 60% 80% Learning Disability Directorate 14% 30% 50% 80% Communities Directorate 3% 20% 50% 80% Specialist Directorate 19% 30% 50% 80% Rapid Tranquilisation In-Patient Directorate 28% 35% 50% 80% Learning Disability Directorate 13% 30% 80% Communities Directorate 5% Specialist Directorate 22% 30% 50% 80% Safeguarding Adults In-Patient Directorate 55% 60% 70% 80% Learning Disability Directorate 57% 65% 80% Communities Directorate 61% 65% 80%

11 Specialist Directorate 62% 70% 80% Respect Level 3 In-Patient Directorate 68% 70% 80% Learning Disability Directorate 63% 65% 80% Communities Directorate N/A N/A N/A N/A Specialist Directorate N/A N/A N/A N/A Respect Level 2 In-Patient Directorate 25% 30% 45% 70% (80% by June 17) Learning Disability Directorate 40% 60% 70% 80% Communities Directorate 10% 30% 50% 80% Specialist Directorate 49% 60% 70% 80% MCA Level 1 In-Patient Directorate 0% 10% 30% 60% (80% by June 17) Learning Disability Directorate 1% 40% 60% 80% Communities Directorate 0% 10% 30% 60% (80% by June 17) Specialist Directorate 7% 30% 50% 80% MCA Level 2 In-Patient Directorate 0% 10% 30% 60% (80% by June 17) Learning Disability Directorate 0% 50% 80% Communities Directorate 0% 20% 40% 60% (80% by June 17) Specialist Directorate 0% 20% 40% 60% (80% by June 17)

12 No Of Assignments Requiring Training 31 Mar 16 No Of Assignments Achieved Training 31 Mar Mar 16 No Of Assignments Requiring Training 30 Jun 16 No Of Assignments Achieved Training 30 Jun Jun Jun 16 (+ Expired in Prev 6 mths) Appendix 4 Mandatory Training Compliance Matrix - Quarter 1 (Info at 30 June 2016) No Subject Level Type of Training Competen ce Frequency Method of Training 1 Equality & Diversity National 3 Years E-Learning % % 68.10% p Increase 4.90% 2 Hand Hygiene National 2 Years Classroom % % 51.70% q Decrease -1.20% 3 Health & Safety Aw areness National No renew al E-Learning % % 53.30% p Increase 10.10% 4 Information Governance National 1 Year E-Learning % % 84.30% p Increase 1.00% 5 Slips, Trips & Falls Level 1 Local 3 Years Classroom % % 66.20% p Increase 5.70% 6 Basic Life Support National 1 Year E-Learning % % 61.20% p Increase 5.00% 7 Immediate Life Support Local 1 Year Classroom % % 72.20% p Increase 19.10% 8 Clinical Risk Assessment & Management Local 3 Years Classroom % % 64.30% p Increase 20.40% 9 Dementia Aw areness Tier 1 National No renew al E-Learning % % 20.20% p Increase 10.60% National 2 Years Classroom % % 72.00% p Increase 6.60% National 3 Years Classroom % % 47.90% p Increase 2.60% Level 1 National E-Learning % % 4.00% p Increase 1.30% Level 2 Local Classroom % % 14.50% p Increase 14.50% Level 1 National 3 Years E-Learning % % 0.10% q Decrease -6.40% Level 2 Local 3 Years Classroom % % 13.00% p Increase 4.30% 13 Mental Health Act National 3 Years Classroom % % 41.60% p Increase 13.10% 14 Medicines Management National 3 Years Classroom % % 15.00% q Decrease -2.80% 15 Rapid Tranquilisation National 3 Years Classroom % % 22.00% p Increase 1.40% Fire Safety Mental Capacity Act (level workbook completions are missing from this report. They will be included in Q2) Deprevation of Liberty Standards (DOLS) Respect Safeguarding Children Comment Level 1 Local 3 Years Classroom % % 7.70% q Decrease -3.30% Level 2 Local 2 Years Classroom % % 43.10% p Increase 9.50% Level 3 Local 1 Year Classroom % % 78.20% q Decrease -1.00% Level 2 National 3 Years Classroom % % 43.20% p Increase 13.50% Level 3 National 3 Years Classroom % % 48.00% p Increase 5.80% 18 Safeguarding Adults Level 2 National 3 Years Classroom % % 62.30% p Increase 3.10% 19 Domestic Abuse Level 2 Local 3 Years Classroom % % 38.70% p Increase 8.60% New 20 Autism Aw areness Local No renew al E-Learning % % 0.04% competency 0.00%