Capability Policy (Performance & Competence) BCUHB... · 3.1.1 Managing the performance of staff, setting and monitoring standards and maintaining appropriate records relating to

Capability Policy

(Performance & Competence)

Rev Date Purpose of Issue/Description of Change Planned Review

Date A October 2009 Initial Issue October 2010

Author Responsible Officer Approved by Date

Policies Workstream Group

Director of Workforce and OD

BCU Health Board

October 2009

Proprietary Information

This document contains proprietary information belonging to the Betsi Cadwaladr University Health Board. Do not produce all or any part of this document without written permission from the BCUHB.

______________________________________________________________________________________________ Policy Ref No: WP3 Version No: 0.06

Page 1 of 26 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure

the version to hand is the most recent

Betsi Cadwaladr University Health Board Capability Policy (Performance & Competence)

Content 1. Introduction

1.1 Scope 1.2 Purpose

1.3 Aims 1.4 Principles 2. Definition of Capability

The Employment Relations Act (ERA) 1996 states that “Capability is assessed by reference to skill, aptitude, health or any other physical or mental quality”. It also indicates that “incapability must relate to the work or the kind of work that the employee was employed by the employer to do”. This must be determined in accordance with employee’s current contractual obligations.

3. Roles and Responsibilities

3.1 Managers and Supervising Staff 3.2 Employees 3.3 Right to Representation

4. Establishing Capability Issues 5. Procedure

5.1 Stage 1 – Informal 5.2 Stage 2 – Formal 5.3 Stage 3 – Third Formal Meeting (Capability Hearing) 5.4 Stage 4 – Appeals against Capability Dismissal

6. Review Meetings 7. References Appendix A Is the Capability or Disciplinary Procedure Appropriate? Appendix B Capability Flowchart Appendix C Capability Action Plan Appendix D Procedure at Capability Hearing/Appeal Appendix E NHS Knowledge & Skills Framework (KSF) Gateway Protocol




Betsi Cadwaladr University Health Board Capability Policy (Performance & Competence)

1. Introduction 1.1 Scope

The Policy applies to all staff employed by the organisation, with the exception of medical and dental staff whose professional conduct and/or competence is dealt with in accordance with Department of Health guidance and referral to professional bodies as appropriate

This Policy applies only to issues of capability - for quick reference a Capability Flowchart is Attached [Appendix B]. Furthermore this Policy must always be applied when deferral of payprogression is a consideration.

1.2 Purpose

The purpose of this Policy is to assist employees to achieve the high standards expected by the organisation by means of a system that addresses substandard work performance in a positive manner, eg providing training, development opportunities and necessary support, without resorting to the disciplinary policy.

1.3 Aim

The aim of the Policy is to ensure that all capability matters are dealt with in a clear, fair and consistent manner in order that employees are fully supported in their endeavours to improve and maintain performance to the required level for the post.

1.4 Principles

The organisation is committed to providing high quality health care through the effective management and development of its employees and believes the effective management of staff performance is an essential part of this. This Policy deals with staff performance, capability and competence and with the resolution of individual problems in relation to these issues.

The Policy does not cover conduct or ill health capability, which are dealt with through the disciplinary policy & procedures, code of conduct, procedures for managing sickness absence and ill health retirement/termination procedures.

This Policy is intended to underpin the normal process of supervisory, support and control where managers allocate work, monitor performance, draw attention to errors and poor quality and, as importantly, highlight work well done. This continuing day-to-day process may include informal assistance in achieving improvement to the required standard, as will the regular KSF development reviews.

On rare occasions, following the full application of this Policy, there may be no alternative to dismissal on the grounds of capability; and any employee dismissed in these circumstances has the automatic right of appeal.




Nothing in this procedure is intended to prevent Managers from dealing with employees’ day to day performance problems as they arise, as such early informal discussions are vital in preventing problems from developing.

2. Definition of Capability

The Employment Relations Act (ERA) 1996 states that “Capability is assessed by reference to skill, aptitude, health or any other physical or mental quality”. It also indicates that “incapability must relate to the work or the kind of work that the employee was employed by the employer to do”. This must be determined in accordance with employee’s current contractual obligations.

A distinction clearly exists between poor performance where the employee is lacking in some area of knowledge, skill or ability, resulting in a failure to carry out the required duties to an acceptable standard (what someone cannot do even when trying his/her best) and poor performance due to wilful refusal or disinclination to work (what someone will not do). The former is a matter of competence and is to be dealt with under this procedure whilst the latter is a matter of conduct and may be dealt with under the disciplinary procedure (see appendix A). This Policy is to be used where there is a genuine lack of capability, rather than a deliberate failure on the part of the employee to perform to the standards of which s/he is capable. Issues of personal misconduct will be dealt with under the Organisation’s Disciplinary Policy.

3. Roles and Responsibilities

3.1 Managers and Supervisory Staff

Managers and supervisory staff carry responsibility for the effective implementation and fair application of this Policy within their sphere of operation. They will therefore be responsible for:

3.1.1 Managing the performance of staff, setting and monitoring standards and maintaining appropriate records relating to staff performance.

3.1.2 Complying with the principles and processes outlined in this document. 3.1.3 Sensitively addressing issues of employee capability and keeping employees fully informed

at all stages of the process. 3.1.4 Ensuring staff have an up to date job description, person specification and Knowledge,

Skills Framework [KSF] post outline that is reviewed annually as part of the Appraisal/ Personal Development process.

3.1.5 Ensuring employees work to the KSF outline which sets out the actual requirements of a post in terms of the knowledge and skills that need to be applied when that post is being undertaken effectively.

3.1.6 Ensuring objectives are realistic and measurable, with timescales set to allow improvement within a reasonable period [normally three months maximum, however this may vary depending on the nature and complexity of the problem/s].

3.1.7 Ensuring, through the use of the appraisal/personal development process, employees are provided with all necessary support, assistance and training to equip them to perform their duties to the required standard.




3.1.8 Maintaining documentation that accurately and fairly reflects the situation. Copies of all capability documentation are to be retained on the employee’s personal file.

Good management practice involves identifying and resolving problems with staff as early as possible and wherever practicable, informally. They are more likely to be resolved if picked up quickly. Managers should bring to the attention of staff as early as possible any dissatisfaction with perceived deficient or unsatisfactory performance. Leaving problems to build up over a period of months or longer without discussing them at the time will not be fair to the employee, and failing to challenge poor performance swiftly may lead to an implication of acceptance. Such discussions should not wait for the development review. They should not be negative but should be constructive as part of the overall search for continuous improvement in the quality of work.

3.2 Employees

Employees are expected to meet the required organisation standards of performance in relation to their jobs. Failure to meet required standards may lead to capability action. If an employee feels it necessary to raise a genuine concern about safe and competent practice, they should do so by following the Raising Staff Concerns / Whistleblowing Policy. If an employee feels that they are being bullied or harassed within work, they should consult the Dignity at Work (Bullying & Harassment) Policy for advice. Employees are encouraged to raise concerns about their ability to carry out their role and to help in identifying the reason(s) for their poor standard of work and how this can be improved

3.3 Right to Representation

Throughout the capability process employees have the right to be supported by a union/staff representative, colleague not acting in a legal capacity. Such individuals support the employee and provide advice and representation during the whole process, with referral to a full time union official if necessary.

4. Establishing Capability Issues

Where a manager first determines there is an issue with a member of staff’s performance, as defined in section 2, they are required to establish whether there could be any contributory organisational or external factors to the deterioration. This may include a lack of proper training and development, a sudden and considerable change in duties, insufficient understanding or guidance, inadequate working conditions, or issues outside of employment.

Consideration of the above will be particularly important if the deterioration in performance is considered to be sudden and the member of staff’s performance had previously caused no concern.

The most difficult part of dealing with substandard work performance is to establish clearly and precisely what constitutes an acceptable standard of performance and then describing in detail the ways in which the employee falls below these standards.




Concerns regarding capability may arise when an employee is failing in a significant or persistent way to carry out their duties in a satisfactory manner. This may be due to a variety of reasons, some of which could be:

4.1 insufficient or inappropriate experience 4.2 lack of adequate training or supervision 4.3 inadequate/inappropriate qualifications 4.4 lack of professional insight 4.5 inability to cope with a reasonable workload 4.6 failure to meet output targets 4.7 changes in the work situation 4.8 poor relationships/conflict with colleagues 4.9 lack of awareness of service requirements 4.10 personal circumstances

Substandard work performance may be identified by : 4.11 Measuring performance against written measurable standards, eg department/operational protocols, 4.12 KSF post outline and associated personal development plan 4.13 Feedback or reports from supervisors/line managers 4.14 Comparison of actual performance against expected performance in terms of job

description, person specification and KSF outline and associated personal development plan

4.15 Comparison with professional codes of practice and performance 4.16 Comparison with fully functioning colleagues/peer group 5. Procedure 5.1 Stage 1 - Informal

Performance issues will normally be dealt with informally in the first instance. In certain circumstances it might be required to refer issues to the formal stage. To determine the level of the capability issue, the following questions should be considered:

5.1.1 What are the indications that the employee is not performing to the required standard? 5.1.2 Have there been complaints about, or criticisms of, the employee’s work from colleagues,

patients, other service users or visitors? 5.1.3 Is there documented evidence to indicate inadequate performance? If so what? 5.1.4 Has the employee indicated a problem or requested help to overcome one?

An Initial informal discussion between the line manager and the employee should focus on the particular performance issues, with the line manager giving a clear explanation of perceived weaknesses in a supportive and non-judgemental manner. It is expected that the employee will respond positively to constructive support and assistance to improve their performance. The line manager’s overall aim is to assist the employee to improve to an acceptable standard. It is crucial that as many aspects of the problem as possible, as perceived by the employee, are unearthed. The employee has the right to be supported if they wish [see 3.3 above].

The informal discussion would normally cover the following areas:




5.1.5 An explanation of how the employee is failing to meet the expected performance standards, referring to the KSF outline and associated personal development plan.

5.1.6 Confirmation or otherwise that the employee has had the necessary training, guidance and support to undertake the job.

5.1.7 The employee to be asked to describe the situation from his/her perspective. 5.1.8 Possible contributing factors to be identified, eg relationships with colleagues,

bullying/harassment, fears of inadequacy/failure, insufficient training, personal circumstances, ill health

5.1.9 Employee to be invited to identify possible solutions to the situation. 5.1.10 The action the employee is required to take to address the issues and any additional

support [eg training, 1:1 supervision, mentoring etc] to be provided. 5.1.11 An action plan with a timeframe for sustained improvement 5.1.12 How performance will be monitored and reviewed over the agreed timeframe. 5.1.13 The employee to be advised of the consequences of not meeting the required standard, ie

moving to the formal stage of the capability process. It is at this stage that notification of possible deferral of pay progression at KSF gateway should be raised [see Gateway Protocol]. Outcome of Meeting

The line manager will record the outcome of the meeting and confirm the main action points in a letter to the employee. The letter must also state that the discussion related to the informal [first] stage of the capability process.

In instances when an employee denies the existence of a problem and following an informal interview, management agrees, it will be confirmed to the employee that no action will be taken and the matter is over.

Where an exploration of these issues identifies a team/department or process failing the manager will work with staff to develop an action plan. The letter should confirm to the employee that this was not an individual capability issue.

The Capability Action Plan [Appendix C] and/or Personal Development Plan to be drawn up between the line manager and the employee must detail the improvements required, the targets and reasonable timescales for improvement. Both the line manager and employee should sign the plan. A copy of the plan will be given to the employee and a copy will be placed on the employee’s personal file. The employee should be advised that they are required to attend regular review meetings throughout the review period [please refer to review meetings section 6].

It is the duty of the manager to ensure that any identified training, 1:1 supervision and/or mentoring is provided in entirety, and evaluated for effectiveness. This should be recorded on e-ksf, within the personal development plan.

If, at the end of the period allowed for improvement [or earlier], the employee has reached and maintained the required standard of performance, then no further action need be taken and this fact should be confirmed in writing to the employee who should be commended for their co-operation and achieving the required standard. Performance will continue to be monitored as part of the ongoing performance review/appraisal process.

If there is no, or insufficient improvement at the end of the review period, the formal procedure should be invoked.




5.2 Stage 2 - Formal

Depending on the severity of the issue there may be a requirement to move to the second or third stage of this Policy

5.2.1 First Formal Meeting

Where the lack of performance continues or where there is a failure to reach the required standard of performance a formal meeting should be arranged with the employee, a different and more senior manager than involved at the informal stage, and a senior Workforce/OD Officer/Manager. The manager should arrange to meet with the employee, giving him/her at least 2 weeks written notice of the meeting. The employee is entitled and encouraged to have an accredited trade union representative, full time trade union officer or BCUHB work colleague not acting in a legal capacity, at the meeting. During the meeting the Manager should formally notify the individual that his/her performance remains unsatisfactory. Reasons for the continued unsatisfactory performance along with examples should be provided and discussed. Reference should be made to the fact that there has been a failure to improve despite previous informal discussions. Details of any additional support that will be provided must be specified. The capability action plan/personal development plan should be reviewed and updated if necessary. An indication should be given of further action that may be taken, eg moving to the next stage of the formal process if the required improvement does not take place and possible deferral of pay progression. Deferral of pay progression at any pay point is permitted where there are significant weaknesses in performance, provided they have been identified, discussed and documented with the staff member concerned and have not been resolved despite opportunities for appropriate training/development and support. Significant weaknesses are those which prevent a staff member from applying consistently across a recognised normal workload, the knowledge and skills specified under the KSF foundation post outline, or for staff above the second gateway, the full range of knowledge and skills specified under the full KSF post outline, without continued supervision and support inappropriate to the post. The outcome of this meeting will be formally recorded in a letter to the employee within five working days of the meeting and a copy kept on the employee’s personal file. The letter will remain on the individuals personal file until satisfactory performance is achieved (with mutually agreed timescales for review). The letter will include:

a) Notification that performance improvement is required under the first formal meeting

stage [5.2.1] of the Capability Procedure b) The areas where performance is unsatisfactory c) A clear explanation of the improvements in performance to be achieved and maintained.

improvement(s) required d) An agreed action plan to achieve improvement underpinned by regular monitoring

meetings e) Timescales will be mutually agreed for improvement with review dates set. f) Action that may follow if the required improvement in performance is not achieved.

If, at the agreed review date, the desired improvements have been achieved, the employee will be informed of the situation and commended for their efforts and co-operation. This outcome will be recorded and the employee will be given written confirmation




within five working days of the review.

If the required standards of performance are not achieved or sustained within agreed timescales, the issue will be dealt with under a Second Formal Meeting.

5.2.2 Stage 2 / Second Formal Meeting

Failure to improve performance following the first formal meeting will result in a second formal meeting with the employee. The process will be as detailed in 5.2.1 with the employee again given the opportunity to answer the points made and provide any other relevant information. It may be felt appropriate at this stage to identify further support/training, or discuss whether redeployment to an alternative work area, if achievable, would be a beneficial and agreeable option for the employee.

At the conclusion of the meeting it should be indicated that failure to achieve and maintain the improvement required could result in dismissal.

The outcome of this meeting will be formally recorded in a letter to the employee within one week of the meeting. The letter will refer to the second [5.2.2] formal meeting stage of the Capability Procedure, contain all necessary additional information and specify a further timescale for improvement [maximum three months] with review dates indicated. At this point there will be deferral of pay progression (refer to KSF Gateway Protocol). The letter must include the statement that the employee may be dismissed unless the required improvement in performance is achieved and sustained within the given timescale.

If, at the agreed review date, redeployment has occurred or the desired improvements have

been achieved, the employee will be informed of the situation and commended for their efforts and co-operation. This outcome will be recorded and the employee will be given written confirmation within five working days of the review. Pay progression will be re-instated from the date of the review.

If the required standards of performance are not achieved or sustained within the agreed timescales, termination of employment will be a consideration.

5.3 Stage 3 – Third Formal Meeting (Capability Hea ring)

Following the second formal meeting and where the desired improvement has still not been achieved termination of employment will be considered at a Capability Hearing. The employee and their representative will be given 2 week’s notice of the Capability Hearing. The line manager will present management’s case and provide a Management Statement of Capability containing all information relevant to the capability process which must be forwarded to the employee with the letter giving notice of the Capability Hearing.

The Capability Panel will consist of :

5.3.1 The manager with the authority to dismiss [usually the Director/Chief of Staff or designated deputy of the work area concerned] 5.3.2 A senior manager from another department / directorate or member of clinical profession 5.3.3 A senior Workforce/OD Manager with no previous involvement or knowledge of the case

The Procedure at Capability Hearing [Appendix D] will be followed. The employee’s line manager will normally present the management case for dismissal, with the




employee and his/her representative given the opportunity to answer the points made and explain any mitigating circumstances that may be responsible for the unacceptable work performance. Witnesses should only be called in person if there is an issue in dispute. The directorate will allocate a note taker to record the decisions taken at the hearing; with the notes to be available at any subsequent appeal against dismissal.

At the Capability Hearing the panel will give serious consideration to:

5.3.4 Redeployment to an identified and funded organisation position 5.3.5 Demotion to a lower banded post 5.3.6 Other suitable alternative solution/s 5.3.7 Termination of employment on grounds of capability with the appropriate notice period

If no suitable alternative employment is available, or the employee declines redeployment or demotion there may be no alternative to dismissal on the grounds of capability. The decision will be confirmed in writing to the employee within three days of the meeting and will provide full details of any redeployment or demotion etc. Should the employee be dismissed the letter will contain:

5.3.8 the reason for dismissal, plus a statement that the dismissal is due to incapability to

adequately perform the duties and responsibilities of the role for which they were employed 5.3.9 details of the capability process undertaken 5.3.10 the effective date of dismissal 5.3.11 the period of notice (max 12 weeks) or pay in lieu of notice if appropriate 5.3.12 final pay details 5.3.13 a request to return all/any organisation property 5.3.14 the right of appeal if dismissed [there is no right of appeal if not dismissed, as action short of

dismissal is an alternative to dismissal]

5.4 Stage 4 - Appeals against Capability Dismissal

Any employee who has been dismissed on the grounds of capability has the right to appeal against the decision. Appeals against dismissal must be lodged in writing no later than 3 weeks from the date of receipt of the dismissal letter and should be addressed to the Director of Workforce & Organisational Development.

The appeal hearing will normally be held within 3 weeks of receipt of the appeal by two

Directors of the Organisation (one of whom should be a Non-Officer). A senior member of Workforce and OD will normally service all formal appeal hearings. Normally the appeal will be dealt with by a more senior manager than the previous level. The appeal panel will have the power to confirm, revoke or substitute the decision of Management. At the appeal hearing, the employee will be given an opportunity to state his or her case and will be entitled to be accompanied by a staff representative or colleague not acting in a legal capacity.

The decision of the panel will be final and will be confirmed in writing within one week of the hearing.




6. Review Meetings

The extent of the periods of monitoring/training, and the frequency of review meetings will need to be agreed in the light of the particular circumstances of each case.

During the agreed monitoring/training period, the manager should hold review meetings at regular intervals (at least every 4 to 6 weeks) to see if the required improvement has been maintained and to discuss any difficulties which may be hindering progress.

These meetings will involve the employee, his/her representative (if required), the manager concerned and a Workforce/OD representative (if required).

During the course of such meetings, the employee will be advised of his/her progress and given the opportunity to comment. One or more of the following outcomes may result:

6.1 Employee is now working satisfactorily and no further action is necessary

6.2 Some progress has been made, but a further period of monitoring/training and review is

required as above.

6.3 Revision of duties or hours of work (including a more flexible working pattern on a temporary basis)

6.4 Suitable alternative employment may be offered (if acceptable and agreed with the employee) Following each review meeting, its outcome will be confirmed in writing to the employee. A copy will be sent to the employee’s representative by authorisation of the employee.

The employee should continue to have an annual appraisal and KSF review. This should take into account, but not focus on the capability issue. The focus should be around other aspects pertinent to achieving the KSF outline requirements, which are unrelated to the capability matter. It should also recognise the progress of the employee against all aspects of the KSF outline (see Appraisal and KSF Review Policy).

The employee should not be disadvantaged in obtaining necessary development and training in order to fulfil or maintain the rest of the KSF outline as a result of the identified capability issue.

7 Case Review

A governance role will be undertaken by Workforce/OD and Trade Union Representatives to monitor and scrutinise the process followed at the end of the process to identify best practice, lessons learned and implemented. The purpose of the review meeting is not to overturn the panels decision.




8. References Other policies and documents referred to in or of relevance to, this document are: � Guidelines for Handling Concerns about the Performance of Staff � Staff Appraisal & Personal Development Review � KSF Gateway Protocol � Disciplinary Policy & Procedures � Sickness Absence Policy � Management of Risks Associated with Stress � Procedures for Managing Sickness Absence � Ill Health Retirement/Termination Procedures � Code of Conduct � Dignity at Work (Bullying & Harassment) � Occupational Health




Appendix A –

Is the Capability or Disciplinary Procedure appropr iate?

Capability, Either: Disciplinary, Or:

1. The person’s efforts are inadequate 1. The person does not make enough effort.

2. They do not seem to have the skills even after relevant training.

2. They are not applying the skills they have.

3. They admit they cannot achieve required standards.

3. They do not seem interested in improving

4. They do not seem able to achieve what is required of them.

4. They do not agree on the problem.

5. They do not seem willing to achieve what is required of them

To decide whether the issue is one of misconduct or capability it is also useful to consider the following:

Cannot do the Job Will not do the Job

Capability Misconduct

1. Is the person inherently incapable of performing as required?

1. Is the person (whatever grade of staff) failing to reach the required standard of performance through his or her own carelessness, or negligence?

2. Is the person unable to achieve the required standard despite making an effort to do so?

2. Is he or she failing to exercise to the full potential such abilities that he or she possesses?

3. Is there a persistent failure to obtain relevant and necessary qualifications which results in the full potential of the job not being recognised?

3. Does the person need to be warned that their conduct must be corrected?

4. Has the person stated they cannot achieve the required standard?

4. Are disciplinary warnings likely to be effective in encouraging a better standard of work performance?

5. Will disciplinary warnings fail to alter performance, as the person is unable to improve?




Yes Follow Disciplinary procedure

Manager recognises substandard work performance

Is it a disciplinary issue?

Stage 1 : Informal meeting

No Follow Capability Procedure

Does the perfor mance improve?

No Yes

No further action required Is it a disciplinary issue?

No Yes

Stage 2 - First Formal Meeting

No further action required

Yes No

Stage 2 - Second Formal Meeting

Stage 3 – Capability Hearing • Redeployment, Demotion or other suitable alternative to dismissal

considered by Capability Panel or • Decision taken to dismiss with appropriate notice

Yes

No further action required

No

Does performance improve?

Does performance improve?

Stage 4 - Appeal Following Dismissal? Yes

Decision of Appeal Panel

Capability Flowchart Appendix B


Page 14 of 26 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure the version to hand is the most recent

Appendix C Capability Action Plan (based on KSF requirements) Identified problem/s with specific examples

Action to Improve Performance

Evidence of improved performance

Who to monitor Timescale to achieve and review date/s

Outcome / Achievement of KSF requirements]




Appendix D

Procedure at Capability Hearing/Appeal 1. The chair of the panel shall:

• Introduce all those present • Ensure the employee is aware of the reason for the hearing • Check whether the employee has/wants representation • Ensure all parties have appropriate documentation • Clarify if either side intends calling witnesses • Advise on the procedure to be followed • Advise that either party may request an adjournment at any time.

2. The employee’s line manager shall state the management case. The case should identify the

extent of the substandard performance and describe the additional support and training identified to correct the capability issues.

2.1 The line manager may call any witnesses and/or refer to written documents to support

their case.

2.2 The employee/representative may question the line manager and witnesses.

2.3 The panel may question the witness.

2.4 The line manager may re-examine their witness.

2.5 The line manager completes the presentation of their case 3. The employee shall state their case, giving any mitigating circumstances that may be

responsible for the unacceptable work performance.

3.1 The employee may call witnesses and/or refer to written documents to support their case.

3.2 Management may question the witnesses

3.3 The panel may question the witnesses

3.4 The employee may re-examine their witnesses

3.5 The employee completes the presentation of their case 4. The line manager sums up the management case 5. The employee sums up their case 6. The hearing is then adjourned for the panel to consider the case in private.




7. Both parties will be recalled to hear the decision which will be notified in writing within three working days. The right of appeal will be confirmed in the letter which will contain full details of the decision to dismiss on the grounds of capability following due process.

Following a capability dismissal this Policy will be adapted for use at an appeal hearing. The chair of the original capability panel will present management’s case at appeal.




Appendix E

NHS Knowledge & Skills Framework (KSF) Gateway Prot ocol The NHS KSF and associated development review process is about investing in the ongoing development of staff fairly and equitably whilst ensuring staff are supported to be effective in their jobs and committed to developing and maintaining high standards of service for the public.

This protocol sets out how the KSF gateways will be used. Underpinning this are the following Principles:

� The gateways should be treated as ‘open’, with staff supported to progress through them. It will be necessary for a manager to inform Workforce/OD/payroll in a situation where the member of staff has not met the requirements of the post outline to pass the gateway, (despite being supported by their line manager and the organisation).

� The process for conducting a personal development review should be no different for a ‘gateway year’ than usual.

� Staff have the right to request a different reviewer at any point during the annual appraisal and

KSF review process. Before agreeing to an alternative reviewer, staff must provide reasons for the request which must be considered by the line manager (or other suitable manager if the line manager is the reviewer).

� The process should operate on a ‘no surprises’ basis. (There will be a normal expectation of

progression with all staff having an equal opportunity to demonstrate the required standard of competence to progress through the gateways and pay points.)

� The Gateway Protocol and process must not discriminate on any grounds, e.g. race, colour, ethnic or national origin, sex, sexual orientation, marital status, disability, age or religion.

1. Pay Gateways

Pay progression will take the form of an annual increase in pay from one pay point to the next within a pay band (subject to the conditions outlined at section 1.8 in the NHS Terms and Conditions handbook, where applicable). However, within each band there are two points (pay gateways) where a formal development review takes place to assess whether the post holder has the necessary competence to perform the job effectively and whether pay progression should proceed.

The gateway review should take place at least 6 months (or exceptionally less by agreement of both parties) before the individual’s incremental date, to enable staff to progress in a timely fashion. This review could be conducted at any point in the year, and could be aligned to an annual performance review / appraisal process - as long as there are no potential deferment issues identified.




During the foundation period (first 12 months in a new role) all staff should have a discussion with their reviewer to review their progress within 6 months. This will demonstrate whether the individual is on track to meet the foundation KSF post outline. 1.1 The Foundation Gateway This is the point at which an individual is assessed against the KSF foundation post outline. The focus is around knowledge and skills that are required for individuals to meet the basic demands of their post. The defined competencies must be met within 12 months of commencing in post, irrespective of where the individual is appointed to on the pay band.

1.2 The Second Gateway This is the point at which an individual is assessed against the full outline for the post, and a decision is made about pay progression. Its purpose is to confirm that individuals are applying their knowledge and skills to consistently meet the full demands of their post – as set out in the full NHS KSF outline for that post. This gateway is positioned within the pay bands as follows:

Pay band 1 before the final pay point Pay bands 2 before the first of last two points Pay bands 5 – 7 before first of last three points Pay band 8a-d before final point Pay band 9 before the final point

2. Pay Progression

Positive progression through the pay points in a pay band is to be anticipated on an annual basis, by individuals applying the necessary skills and knowledge to the demands of the post.

At the personal development review preceding a gateway review (i.e.12 months before the gateway review) or on appointment, the post holder will be informed that the next formal review will be a gateway review where decisions about pay progression will be made. Any discussion must identify the knowledge and skills that the individual needs to develop and apply, and the member of staff given opportunity to achieve the necessary competence. These needs must be formally recorded within the Personal Development Plan (PDP).

The KSF reviewer and post holder will agree any action required to meet the relevant gateway and what evidence could be used to demonstrate the required levels. This will be noted within the KSF documentation.

Progress should be jointly confirmed during the year so that any issues or concerns can be identified and addressed. This will ensure there are ‘no surprises’ at the formal gateway review. No deferment should occur if an individual is away from work in the long term i.e. long-term sick or maternity leave - subject to no recorded significant weaknesses in performance being identified prior to commencement of leave.




3. Gateway Procedure It is only at gateways, or if concerns have been raised about significant weakness in undertaking the post, that the outcome of a review might lead to deferment of pay progression, subject to paragraphs 6.26 and 6.27 from NHS Terms and Conditions of Service Handbook:-

“6.26 Where significant weaknesses in performance i n the current post have been identified and discussed and documented with the staff member concerned and have not been resolved despite opportunities for appropriate trai ning/development and support, exceptionally pay progression may be deferred at an y pay point until the problems are resolved.

6.27 Significant weaknesses are those which prevent a staff member from continuing to apply consistently, across a recognised normal work load, the knowledge and skills specified under the KSF foundation post outline for the foundation gateway or, for staff above the second gateway, the full range of knowled ge and skills specified under the full KSF post outline without continued supervision and support inappropriate to the post.” If issues have been identified, “there must always have been formal notification of any concern to the individual by their reviewer. An act ion plan must have been drawn up to try to remedy any issues before deferral of (pay) progr ession can be raised.” (The NHS Knowledge and Skills Framework and the Development Review Process October 2004, 3.2.1) Where pay deferment is likely, Staff Capability Procedures should be followed and formally recorded. If the reviewer is not the individuals’ manager, the senior manager should take over the review process at this point. Refer to:

• Capability Policy, 5.1 Procedure, Stage 1. • Flowchart appendix 3.

3.1 Organisational constraints The individual will progress automatically through their gateway if the individual is unable to demonstrate application of the skills and knowledge defined in the KSF post outline due to managerial or organisational constraints, such as:

• Financial constraints • Lack of Performance and Development Review • Lack of managerial support as agreed in their PDP • Release from the workplace due to limited staffing • Lack of learning opportunities within the workplace

If the Reviewer is on an agreed/recognised leave of absence (e.g. sickness, maternity leave), an appropriate alternative reviewer must be identified by the senior manager. If no alternative reviewer is available, the individual will progress through the pay band and the review to take place on the reviewer’s return to work.




3.2 Individual constraints

If it can be demonstrated that the individual did not pursue the necessary education, training or development outlined in their PDP and it was not as a result of the organisation or reviewer's inaction, pay progression to the next pay point will be deferred. The period of deferment will reflect the time needed to complete the action plan agreed to bring the job holder's competence up to the requirements of the KSF outline. Where this is the case an agreed action plan should be put in place to ensure the individual progresses through the gateway as soon as possible. 3.3 Deferral Where it is agreed progression will be deferred, Workforce/OD/Payroll Services must be informed of the deferment by the senior manager and pay progression stopped using a Staff Change Form. The form must be received and actioned by payroll services prior to payroll cut off/positive reports date. Gateway Deferral Form - KSF1 Deferral (Appendix E2) must be completed and kept on Individuals Personal File. 3.4 Resuming progression Pay progression will resume from the date on which the capability process and subsequent development review confirms that the individual/reviewee is applying the level of knowledge and skills specified in the KSF post outline. The reviewer will inform Workforce/OD/payroll services using Staff Change Form. Gateway Reactivation Form – KSF2 Reactivation (Appendix E3) must be completed and kept on Individuals Personal File. There is no backdating of pay for the deferred pay period. 4 Maternity and Sickness Absence Deferment should not occur if an individual is away from work in the long term, i.e. long-term sick or maternity leave subject to no recorded significant weaknesses in performance being identified. Where the individual is on a prolonged period of absence at the date of their review they will progress through their gateway (subject to no recorded significant weaknesses in performance being identified.) On their return they will go through a review with their reviewer to ensure their competence. Staff can be deferred from progressing through a gateway if performance issues have been raised prior to the deferment and formally recorded outside the KSF review process.




5 Career Break(s) Staff on a formally agreed career break will have their progress along a pay band deferred until their return. This must be carried out by the reviewer prior to the career break starting. If an individual returns from a career break during a gateway year, a development review must be arranged within the first 4 weeks in order to produce an agreed action plan. Either party may request deferment of gateway until such an appropriate time provided that this is agreed by those concerned.

6 Disputes between the Reviewer and the Job Holder

If the Individual and reviewer are unable to agree at any stage of the Gateway Review the aim should be to settle the disagreement fairly and as near as possible to the point of origin in an informal manner. It should be simple and rapid in operation. ‘If the individual member of staff and their review er cannot agree, either one has the right to seek support on an informal local basis from a thir d party, such as the line manager of the reviewer, someone from the human resource departmen t, or a trade union/learning representative. This third person may seek further information from either the reviewer and/or the individual member of staff. They will lo ok at the information from both and come to an objective decision that is fair and non-discr iminatory. If the informal process cannot address the problem, then the individual member of staff can take their case through local grievance procedures. If pay has been withheld, the n if the individual’s case is upheld pay will be back-dated to the point at which pay progre ssion should have occurred. This should be the exception rather than the rule as one of the principles of the system is that it is based on ‘No Surprises’’ . (The NHS Knowledge and Skills Framework and the Development Review Process October 2004)




Appendix E1

Definitions

KSF Pay Gateway. A defined point on a pay band where a decision is made about pay progression as well as development. Each pay band has two ‘Pay Gateway’ points. The KSF Gateway is linked to the KSF outline for the post. KSF Post Outlines A KSF Post Outline sets out the dimensions and levels of skills and knowledge that apply to a particular post. The outline specifies areas of practice/activities that apply to a post; this provides the link to effective learning and development for an individual in order to fulfil the requirements of the post. Individuals (reviewees) have a responsibility to provide supporting evidence demonstrating competence at development review. Post Outlines must properly reflect the actual demands of a post without imposing unnecessary requirements.

KSF Foundation Post Outline This describes the initial level competence required for the post within the first twelve months. The individual post holder must be able to demonstrate that they meet the KSF Foundation Post Outline within one year of being appointed to the post at their Foundation Gateway Review. KSF Full Post Outline This is a Post Outline with defined levels of competence for the post, and agreed competence for the second gateway. The individual post holder must be able to demonstrate that they consistently meet the full KSF Post Outline at their Second Gateway Review.

KSF Development Review A development review is an ongoing cycle of review, planning, development and evaluation for individuals against the demands of their posts. It is the responsibility of the reviewer and reviewee to participate fully in the process. A copy of the recorded outcome should be kept by both parties. The whole system of Development Reviews is based on the principle of 'No Surprises'. “It is expected that reviewers will have regular informal discussions with individual staff members throughout the year. The development review is when all the discussions taken place throughout the year are brought together and jointly reflected on in a structured way.” (The NHS Knowledge and Skills Framework and the Development Review Process October 2004, 3.2.1) Incremental Dates Following pay deferral; when pay progression is reactivated, the individual retains their original incremental date (not the date where pay progression is reactivated) e.g. an individual which has their incremental date at 1st October 2006 and who’s pay is deferred at the gateway; they take10 months to resolve the issue and pay progression is reactivated and they proceed to the next pay/incremental point on 1st June 2007(this does not become the new incremental date). Therefore on 1st October 2007 the individual will move up another incremental point.




Form KSF 1- Deferral Gateway Deferral Form Name of individual:

Department:

Job Title:

Band

Directorate:

ESR Employee ID Number Foundation Gateway: Yes/No

2nd Gateway: Yes/No

Incremental Date:

Reason/s for Deferral: (Please identify dimensions and indicators not achieved) Reason/s not achieved: Agreed Review Date: Line Manager

Staff

Third Party (if in attendance)

Name : Signature:

Name: Signature:

Name: Signature:

Job Title:

Job Title: Job Title:

Date Manager Informed Postholder ______________ Date Payroll Informed _______________ Please ensure relevant details are copied onto Staff Change Form and forwarded to Payroll for action. Include the following information on the Staff Change Form: under ‘..change details’ insert ‘First/Second Gateway - Deferral of pay Progressio n. Foundation/Full KSF Outline not achieved.’ under ‘Effective dates from’ insert the Incremental/Gateway Date under ‘To (approximately)’ insert ‘until further notice’ Keep a copy of the completed form on the individual’s Personal file.

Appendix E2




Appendix E3 Form KSF 2 - Reactivation

Re-Activation of Pay Progression

Date of Review:

Actions achieved to meet all dimensions & indictors:

Next Review Date:

Line Manager

Staff

Third Party (if in attendance)

Name : Signature:

Name: Signature:

Name: Signature:

Job Title:

Job Title: Job Title:

Date Payroll Informed _____________ Payroll to Re-Activate Pay According to Date of Rev iew Date Manager Informed Postholder __________________ _________

Please ensure relevant details are copied onto Staff Change Form and forwarded to Payroll for action. Include the following information on the Staff Change Form: under ‘...change details’ insert ‘Re-activation of pay Progression. Foundation/Full KSF Outline achieved.’ under ‘Effective dates from’ insert the Review Date under ‘To (approximately)’ leave blank Keep a copy of the completed form on the individual’s Personal file.




Appendix E4 Process for employing Gateway Protocol & its relati onship with the Capability Procedure

Issue first identified with individual’s development.

Informal discussion with individual • Clarification of actions

required by Personal Development Plan

• Focused future learning & development to help overcome issue

Issue resolved?

Yes No Formal Notification of concerns raised by Reviewer prior to review date

• Jointly agree action plan and timescale prior to formal gateway review

Invoke Capability Procedure: Informal Stage

Formal Gateway Review. Foundation/Full KSF Outline requirements met?

Yes No

Proceed through Gateway to next incremental point

Agree Pay Deferral Action Plan to address issues and set next Review Date

Issue Resolved?

Yes No

Capability Procedure: Invoke First Formal Stage

Capability Procedure Invoke Second Formal Stage

Action Plan not achieved by Individual

Documents

Capability Policy (Performance & Competence) BCUHB... · 3.1.1 Managing the performance of staff, setting and monitoring standards and maintaining appropriate records relating to