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INTERNAL AUDIT REPORT

Draft

Powys Teaching Health Board

Rostering – Effective Utilisation of Workforce

Audit Review

2014/15

Private and Confidential

NHS Wales Shared Services Partnership

Audit and Assurance Services

NWSSP: Audit and Assurance (Specialist Services unit)

2


Rostering – Effective Utilisation of

Workforce Audit Review

Report Contents

NHS Wales Audit & Assurance Services Page | 1

CONTENTS

1. EXECUTIVE SUMMARY .................................................................. 3

1.1 Introduction and Scope ............................................................ 3 1.2 Opinion and Key Findings ......................................................... 3

2. AUDIT APPROACH AND SCOPE .................................................... 12 3. SIGNIFICANT AUDIT FINDINGS ................................................... 13

3.1 Assurance Summary .............................................................. 13 3.2 Design of System / Controls ................................................... 13

3.3 Operation of System / Controls ............................................... 13 3.4 Audit Recommendations ......................................................... 14

Review reference: PtHB14/15/19

Report status: Draft Fieldwork commencement: 05 November 2014

Fieldwork completion: Management debrief meeting:

Draft report issued:

13 January 2015 13 January 2015

13 February 2015, 24 April

2015 Management response received:

Final report issued: Auditor/s: Kate Webb, Head of Internal

Audit Catherine Ketteringham,

Principal Auditor Rhian Spencer, Auditor

Executive sign off Julie Rowles, Director of Workforce & Organisational

Development Distribution Paul Labourne, Assistant

Nurse Director; David Long, Deputy Director

of Workforce;

Appendix A Management Action Plan

Appendix B Audit Assurance Ratings Appendix C

Appendix D

Recommendation Priorities

Responsibility Statement




Report Contents


Claire Nicholas, Head of

Corporate HR Practice and Development;

Jason Crowl, Locality Lead

Nurse/Head of District Nursing;

Michael Cope, Interim Head of Estates for Maintenance

Operations; Nathalie Thomas, Business

Development Manager, South Locality,

Chrissie Owens, Senior Nurse, South East Powys;

Cate Langley; Head of Midwifery and Sexual Health;

Donna Owens, Lead Midwife – North Powys/Clinical Risks;

Lesley Sanders, Senior Sister;

Jo Mayall, Ward Manager; Janet Bethell, Senior Sister;

Julie Lewis, Sister; Helen Farr, Domestic

Supervisor

Committee Audit Committee Workforce & OD Committee

ACKNOWLEDGEMENT

NHS Wales Audit & Assurance Services would like to acknowledge the time and co-operation given by management and staff during the course of this

review.




Main Report


1. EXECUTIVE SUMMARY

1.1 Introduction and Scope

In accordance with the 2014/15 internal audit plan, a review of Rostering and the effective utilisation of workforce was carried out.

The audit sought to provide assurance that the systems currently operating for the management and deployment of the workforce are doing so in an

efficient and effective manner and where appropriate corporate policies and

procedures are being complied with.

The audit encompassed examination of annual leave, sick leave and the

use of temporary staff within the Powys teaching Health Board.

1.2 Opinion and Key Findings

We are required to provide an opinion as to the adequacy and effectiveness

of the system of internal control under review. The opinion is based on the work performed as set out in the scope and objectives within this report.

An overall assurance rating is provided describing the effectiveness of the system of internal control in place to manage the identified risks associated

with the objectives covered in this review.

The level of assurance given as to the effectiveness of the system of internal control in place to manage the risk associated with Rostering and the

effective utilisation of workforce is No Assurance.

Key findings:

No

assu

ran

ce

- +

Red

The Board has no assurance that

arrangements to secure governance, risk management and internal control, within

those areas under review, are suitably designed and applied effectively. Action is required to address the whole control

framework in this area with high impact on residual risk exposure until resolved.




Main Report


We have identified 12 high priority issues that require prompt management action, which are summarised below:

1) Lack of Policies/Out of Date Policies

We reviewed several policies which are relevant to this audit and

identified the following:

A draft Rostering Policy which will be updated following receipt

of this internal audit report. This will then be finalised so that staff are clear of the rules to follow when rostering;

Bank Staff Operational Policy - The Bank Staff Operational Policy was issued in March 2011 and was due for review in

October 2014. The policy is out of date and does not reflect

practices currently operating;

Policy and Procedure for the approval of Locum and Agency

Staff - This policy was last issued in May 2010 and was due for review in August 2013. Whilst, there have been no changes in

legislation that will affect the policy, if some policies have to be reviewed, it would be prudent to update all policies connected

with rostering; and

Professional Nursing & Midwifery Staffing Standards - This

policy was approved by the Clinical Effectiveness Committee on the 19 January 2015. It is now intended to present this policy

to the Senior Nursing and Midwifery team after which wholesale implementation across Nursing will be carried out.

Management Response:

Responsible Officer:

Timeframe:

2) Staffing Establishments

The All Wales Nursing Principles were produced in April 2012 by the

Chief Nursing Officer. Spread sheets were drawn up identifying the impact of nursing principles for each ward and this was incorporated

into the funded nursing establishment. However, testing noted a low level of awareness of the establishment and skill mix agreed for each

ward.

There was no agreed skill mix or establishment listing for Estates

Staff in Bronllys Hospital. No establishment list could be provided for Catering at Bronllys Hospital.




Main Report


Maternity services use Birth Rate Plus acuity tool. The acuity tool is

endorsed by Welsh Government. The staffing establishments are formally reviewed every three years.



Timeframe:

3) Rostering for Wards

A number of localised systems were noted to be operating in Wards. None of the staff spoken to who had responsibility for the preparation

of rosters had received any form of training.

We identified that rosters are created 4-6 weeks in advance, however

rosters are not being appropriately signed off. The overall

presentation of rosters was found to be very poor and hard to follow, this was generally as a direct result of the number of amendments

made after the roster had been completed.

Testing was carried out on the application of the skill mix and

differences were noted between the Establishment Listing and the rosters.

One ward was identified where rosters are retained only for 2 years before they are destroyed (rather than the 4 years required).



Timeframe:

4) Rostering for Estates, Bronllys Hospital

Rosters are not drawn up for staff working in Estates. Officers work standard hours. Following discussions with Supervisors and the

Interim Head of Estates for Maintenance Operations, it was confirmed

that records detailing the whereabouts of officers and work carried out by them could not be relied upon. This was as a result of records

e.g. job sheets which were not fully completed and which were not checked by Supervisors before being signed off. Furthermore, there

were no records available for testing for the period April – September 2014.



Timeframe:




Main Report


5) Rostering for Catering, Bronllys Hospital

Rosters should be prepared by the Domestic Supervisor, but currently they are being created by the Lead Cook. Assurances cannot be

provided that the rosters are prepared fairly and take into account the wishes of all employees. The rosters are not authorised by the

roster manager.



Timeframe:

6) Approval of Locum and Agency Staff

Audit testing identified that this policy is not being applied

consistently. Prior to the booking of Agency Staff written

authorisation must be obtained from the Locality General Manager or Director on Call. Written evidence, confirming authorisation, was not

available for Agency Staff employed at Brecon War Memorial Hospital (Epynt Ward) and Machynlleth (Graham Davies Ward).

The Agencies used in testing were Thornbury Nursing Services Ltd and CLCA Co Ltd. Neither of these Agencies are on the framework for

Agency Nursing Services. The All Wales contract expired on 30/09/2014. A new contract will commence on 1 March 2015 (the

award recommendation is currently with the Health Minister).

We have been informed that no Agencies on the previous contract

provide services to Mid Wales despite contract documentation which shows that there were 8 agencies that provided these services on an

All Wales basis. Clarification in respect of the use of Agency Staff by the Health Board is currently being sought from the Head of

Procurement, Shared Services.

The Policy and Procedure for the Approval of Locum and Agency Staff states that “PtHB will contract to one agency per discipline and obtain

a written undertaking that any staff used will have an up to date Criminal Records Bureau check at the appropriate level identified

and/or registration with the Independent Safeguarding Authority (ISA) as required by law, current professional registration and

employment references. This will be in line with the All Wales Guidelines “Contract Specification for the use of Agency Staff”.

As the Agencies used are not on the framework, they would not have been taken through any pre-qualification checks.






Main Report


Timeframe:

7) Lack of effective system for the deployment of Bank Staff

Inconsistencies in the application of the policy and the use of Bank

Staff were identified. Significant time is spent by Ward Staff trying to book bank staff using out of date lists. The lists do not record the

availability of staff and contain names of staff who have not worked for the Health Board for a number of years.

A poor segregation of duties was noted where one member of staff responsible for the preparation of rosters is also employed by the

bank and in effect responsible for booking herself.



Timeframe:

8) Training of Bank Staff

Testing identified at least half the names on the Bank Staff database had not received mandatory training. It is acknowledged that the

database is currently being reviewed and where appropriate errors and anomalies are being investigated. Of the 661 names on the

database and after manually discarding duplicate names a total of 349 bank staff were identified as not having had mandatory training.

Examination of the list would also indicate that the majority of Bank Staff have not received corporate induction.



Timeframe:

9) Application of Overtime and Hours over Contract Policy and

Procedure

Overtime

Testing identified that the Policy is not being applied correctly. The

overtime authorisation process is not being followed or completed.

TOIL

The Overtime policy details how TOIL should be applied. 40 records of TOIL were tested and several different methods of recording TOIL

were identified during the course of the audit, none of these were in accordance with the policy.

In Estates, Bronllys Hospital, no formal records of TOIL were maintained for the period April – September 2014.




Main Report




Timeframe:

10) Professional Nursing & Midwifery Standards

In the absence of a published policy on Professional Nursing and

Midwifery Staffing Standards, assurance cannot be given that all staff are aware of the procedures to follow in the event of an identified

shortfall in staff which may affect the safety of patients.

Of the 7 instances identified by Internal Audit testing, where shifts

were understaffed (based on the establishment information given to us), none of these had been reported on Datix. Internal Audit were

informed that this situation might not always result in a Datix report

being generated. This would only take place if the Ward Sister thought that the staffing levels were at a level that could compromise patient

care. We encountered differing views on the process to follow, and therefore the Policy needs clarification so that there is no

misunderstanding.

There is an Operational Policy for Powys Teaching Health Board

Maternity Services. This Policy includes an escalation procedure.



Timeframe:

11) Working Time Regulations Policy and Procedures

All staff were aware of this procedure in respect of the number of

hours they were permitted to work. However, it was noted that on frequent occasions in many of the wards visited e.g. Llanidloes and

Machynlleth, breaks were not being taken overnight and

compensatory rest was being given. Compensatory rest appears to be applied consistently and in many cases appears to be the norm

i.e. expected. The Working Time Directive should not be applied in this manner. On frequent occasions the time accrued was not being

taken back within 2 weeks.



Timeframe:




Main Report


12) Application of All Wales Sickness Absence Policy

Out of the 23 sickness records we looked at for short term sickness absence; 15 instances had no record of the initial contact made by

staff to notify the sickness, 6 instances had no back to work interviews completed and 2 instances where no records could be

found.

Out of the 15 records we tested for long term sickness absence; 11

records had all the necessary sickness documentation required (we were unable to view the remaining 4 records at Brecon War Memorial

Hospital – reasons provided in Appendix A). 8 records did not provide the date of the return to work interview (3 of these are employees

which have not returned to the organisation and are still on long term

sickness).

Out of the 5 records we tested for 3+ triggers, only 1 record had all

the forms and documentation completed (Brecon War Memorial Hospital). 1 record had the point of contact form filled in but no back

to work information completed, and the 2 records at Bronllys Hospital had no point of contact forms filled in but had the back to work

information completed. 1 record was with HR (Brecon War Memorial Hospital).

There were two areas tested where staff were put back on the trigger points due to insufficient documentation maintained by management.



Timeframe:

We identified 4 medium priority issues which we consider require

management’s attention and provide scope for improvements to be made.

These concerned:

1) Recruitment of Bank Staff

During the course of the audit, reference was made on a number of occasions to the length of time taken by HR to complete the

recruitment process. Testing identified that the overall process could be expedited if Recruiting Managers (e.g. Ward Sisters) set interview

dates and took responsibility for chasing up applicants for references and other required information.



Timeframe:




Main Report


2) Accuracy of Bank Staff Timesheets

Testing carried out identified differences between the time recorded on the roster and the time claimed on timesheets. Of the 60 records

examined 8 differences were identified. As the Rosters were not correctly updated when shorter/longer shifts were being worked the

integrity of the staff has to be relied upon when recording actual hours worked.

Testing did not identify Bank Staff working for Maternity Services for

the period tested.



Timeframe:

3) Delivery of Contracted Hours

The current method of rostering does not provide a readily available

picture confirming whether contracted hours have been worked. Testing to verify whether standard contracted hours had been worked

found inconsistent methods of data recording.

Due to local arrangements operating, which are not always recorded

on the roster reconciliation of hours worked to hours claimed is not a transparent process. Standard contract hours are paid regardless of

whether they have been worked. Timesheets are submitted in order

that the enhanced payments can be made.



Timeframe:

4) Annual Leave (Operation)

With the exception of Maternity Services, annual leave is not being

entered onto ESR and is not being approved prior to being taken. Poor and inconsistently completed records were found to be

maintained on the wards with leave not being authorised prior to being taken.



Timeframe:

Good Practice

Although we have raised a number of issues, we did identify:




Main Report


Good practices were found to be operating within Midwifery Services.

All leave tested was entered onto ESR prior to being taken and a current policy provides escalation guidance in the event of a shortfall

in staff.

Without exception all staff operating the Ward Rosters put a

significant amount of hard work into the preparation of rosters. There are elements of good practice which were noted and examples of

good team working.

A three week rostering system was found to be operating for the

switchboard at Brecon Hospital where each officer works the same shift pattern every three weeks. This appeared to be operating

effectively.

A number of Agency Staff have been employed by the Estates Department. It is understood that this was necessary to address

issues raised by the Health and Safety Executive. Evidence was provided to confirm that a Variation from Financial Regulations had

been obtained.




Main Report


2. AUDIT APPROACH AND SCOPE

The approach to audit assignments is risk based, where the risks are identified with the lead manager. Controls would then be identified to

manage those risks and the assignment scope designed to provide assurances on those issues.

The outcomes of this review can be linked or contribute to Standard 24: Workforce Planning, 25: Workforce Recruitment and Employment Practices

and 26: Workforce Training and Organisational Development of the Standards for Health Services in Wales.

The audit assignment has been allocated an assurance rating, dependant on the level of assurance Internal Audit are able to provide. There are four

potential levels of assurance available (Substantial, Reasonable, Limited

and No Assurance), along with three recommendation priorities (High, Medium and Low) that are described in Appendix B and C.

The purpose of the review is to assess the adequacy of internal controls in operation and highlight weaknesses to the management with advice to

resolve issues, improve controls and minimise future occurrences.

The audit included desktop based review of relevant documentation

including payroll reports, TOIL records and annual leave records, staff interviews and examination of a sample of Rosters.

The risks considered in the review are as follows:

i. Non-compliance with corporate policies;

ii. Failure to achieve the most efficient and effective use of resources via effective rota management;

iii. Leave and sickness absence is not being accurately recorded or planned for;

iv. There is no accurate record in place to confirm hours contract hours

have been worked; v. Poor controls exist with regard to the use of temporary staff;

vi. There is no matching of temporary staff requests to time worked and paid for temporary staff;

vii. Temporary staff are not appropriately qualified and have not been vetted in terms of appropriate clearance e.g. DBS;

viii. Hours worked are not being monitored to ensure compliance with working time directive; and

ix. Management information is not available to assist effective decision making.




Main Report


3. SIGNIFICANT AUDIT FINDINGS

3.1 Assurance Summary

The summary of assurance given against the individual objectives is described in the table below:

ASSURANCE SUMMARY

Audit Scope

1 Policies and

Procedures √

2 Preparation of Rosters √ 3 Approaches to

covering shortfalls in Rosters

√

4 Working Time Directive

√

5 Attendance Management

√

3.2 Design of System/Controls

The findings from the review highlighted 2 issues that could be classified as a weakness in the system/control design for the management of

Rostering and the effective utilisation of Workforce. These are identified in the main body of the report as (D).

3.3 Operation of System/Controls

The findings from the review have highlighted 15 issues that are classified

as weaknesses in the operation of the designed system / control for the management of Rostering and the effective utilisation of Workforce. These

are identified in the main body of the report as (O).




Main Report


3.4 Audit Recommendations

A range of recommendations have been made to address the issues identified and these have been accepted by management. A summary of

these recommendations by priority is outlined below.

Priority H M L Total

Number of recommendations 12 4 0 16

The full audit findings and recommendations are detailed in Appendix A

together with the management action plan and implementation timetable.


Rostering – Effective Utilisation of Workforce Audit Review

Appendix A

Management Action Plan

NHS Wales Audit & Assurance Services Appendix A Page | 1

Policies and Procedures

Finding 1 Impact

Lack of Policies/Out of Date Policies (Design)

We reviewed several policies which are relevant to this audit and identified the

following:

Rostering Policy

A draft Rostering Policy has been developed. This draft policy has been written in conjunction with staff side (September 2014) and the Workforce Policy Review

Group (October 2014). Following issue of the Draft Policy and publication on the intranet, a number of comments were received. At the time of writing this report

these comments were being analysed. The Policy will be updated for any pertinent points arising from this Internal Audit Review.

The purpose of the policy is to ensure the effective utilisation of the workforce through efficient rostering to include the management and monitoring of annual

leave, sick leave and temporary staff within the organisation. This policy applies to all staff covered by Agenda for Change Terms & Conditions.

Examination of the policy noted reference being made to the measurement of Key

Performance Indicators. Issues identified from testing are as follows:

Quality of Service Provision – the agreed baseline of staff was not always

known by the roster creator; Fairness of Staff Allocation – the audit trail to support equity of requests is

poor, European Working Time Regulations are not being adhered to in terms of rest breaks;

Policies are either not in place or out of date which can lead to

inconsistent application of Policies across the Health Board.

Key performance data cannot be produced to enable management to

understand the efficiency of how staff are deployed.



Appendix A



Effectiveness of down time management – we identified management issues in terms of annual leave, sickness and lieu time management; and

Rostering Efficiency – we identified issues with additional hours, and overtime worked.

The Policy states that the Compliance Monitoring for Nurses will take place through the number of Shifts of Concerns being reported related to any given

area in line with the Professional Nursing & Midwifery Staffing Standards.

The Compliance Monitoring would only satisfy the Quality of Service KPI. Currently all rosters are manually prepared and the collection of data to enable

these measurements to be made is not possible.

We acknowledge that there is a monthly benefits tracking report that provides

usage of Bank, Agency, Additional Hours and Overtime. The Sickness Absence rate, staff in post, recruitment and compliance with Statutory and Mandatory

Training.

The Management Reporting requirements of the Policy would not be fulfilled until

an e-rostering system is implemented. If the Rostering Policy was to be issued as a final document, the Health Board would be non-compliant in this area.

The Health Board would also be non-compliant in respect of other practices currently operating:

7.7 Employee Responsibility: The Policy states that no holiday arrangements should be arranged until the leave request has been

sanctioned. With the exception of Midwifery, leave is not input onto the ESR

system until after it has been taken. Manual records are currently maintained. Examples were noted where leave had not been recorded and

approved prior to it being taken; Epynt Ward, Brecon War Memorial Hospital. All leave tested was evidenced on the ESR system.



Appendix A



8.2.2 Requests: The Policy states that a maximum of 20% of contracted shifts may be requested per week. Currently Self Rostering is operating at

Twymyn Ward, Machynlleth and the Graham Davies Ward, Llanidloes.

The Rostering Policy applies to all staff covered by the Agenda for Change.

Reference should therefore be included within the policy detailing that responsibility for effective time management and recording is applicable to all

staff. Appropriate time management systems should therefore operate and be

available upon request.

Training should be provided to all appropriate staff following the introduction of

the new Rostering Policy to ensure that staff understand their roles and responsibilities and the principles to which they are to adhere.

Bank Staff Operational Policy

The Bank Staff Operational Policy was issued in March 2011 and was due for

review in October 2014. The policy refers to the “Professional Bank Staff Co-ordinator”, however this role is not currently operating within the Health Board.

As a consequence, the policy describes the role of the Professional Bank Staff Co-ordinator, which does not reflect current practice. The policy needs to be updated

to include:

Processes to ensure that the allocation of work to bank staff is carried in a

fair and equitable manner - this should include additional authorisation where officers who are in effect booking themselves for bank shifts are

involved;

Roles and responsibilities e.g. ward sisters, ward clerks, Human Resources; A revised bank staff database needs to be put in place and made

operational. The database needs to be maintained and regularly updated;



Appendix A



Processes to record contact made with bank staff, thus ensuring that a record is kept of persistent refusal by bank staff to work shifts. Such a list

should include dates that bank staff were contacted; Processes to ensure that bank staff are appropriately qualified and have

undertaken all relevant training and processes to identify when these are outstanding; and

Processes to ensure that all bank staff have access to Personal Development

Plans and mechanisms to identify where these are outstanding.

Professional Nursing & Midwifery Staffing Standards

This policy was approved by the Clinical Effectiveness Committee on the 19

January 2015. It is now intended to present this policy to the Senior Nursing and Midwifery team after which wholesale implementation across Nursing will be

carried out. The purpose of this policy is to support the maintenance of safe nursing and midwifery staffing levels and where staffing levels are at a level below

that considered acceptable this is reported, monitored and action is being taken.

An Operational Policy for PtHB Maternity Services was noted, however, for the

period tested implementation of the policy could not be tested as there were no

instances of understaffing.

Policy and Procedure for the approval of Locum and Agency Staff

This policy was last issued in May 2010 and was due for review in August 2013. The copy of the policy available on intranet has been updated to state “it is

acknowledged that this policy is overdue for review. There have been no changes in legislation that will affect the policy and it therefore remains extant and fit for

purpose.”

Recommendation 1 Priority



Appendix A



The policies for Rostering, Bank Staff Operational Policy, Professional Nursing & Midwifery Standards and the Policy and Procedure for the approval of Locum and

Agency Staff need to be reviewed and updated to reflect standard operating procedures.

A programme of learning and development for staff with responsibilities for operating these policies should be developed and put in to place as soon as

possible so that staff are clear of the standards to which they need to adhere.

Management Response Responsible Officer/Deadline

The above policies are being reviewed in partnership. A training roll out plan will

be developed for these policies to ensure all responsible managers are clear about their responsibilities and accountabilities within the policies.

.

Head of Corporate HR Practice and Development

Deputy Director of Nursing

July 2015

High



Appendix A



Preparation of Rosters

Finding 2 Impact

Staffing Establishments (Operation)

Wards

During our audit, we visited the following wards:

Llewellyn Ward, Bronllys Hospital;

Epynt and Y Bannau Wards, Brecon War Memorial Hospital;

Graham Davies Ward, Llanidloes Hospital; and

Twymyn Ward, Machynlleth Hospital.

The All Wales Nursing Principles were produced in April 2012 by the Chief Nursing Officer and the following principles were identified:

Professional judgment will be used; A minimum of 1:1 Whole Time Equivalent/bed ratio;

7 patients per Registered Nurse per shift during the day; 11 patients per Registered Nurse by night;

Skill mix generally 60:40; Headroom (uplift of 26.9% to cover annual leave, sickness absence,

training, etc); Ward activity and demand will be considered as well as the number of beds,

environment and ward layout; and

The Ward Sister will be supervisory and additional to the numbers.

Wards/departments are operating

with either too many or too few staff.

There could be a negative impact on

the quality of care provided to patients.

Ineffective use of resources if areas are overstaffed when this is not

required.



Appendix A



We understand that a paper was presented to The Executive Team on “Safe Inpatient Staffing” on 3 September 2014. The purpose of this paper was to

discuss and agree the best way forward for the development of inpatient nursing establishments over 2014/2015. Prior to this date budgets were negotiated at a

Service Level based on Nursing Principles and professional Judgement.

There is a requirement that staffing establishments are reviewed annually or

following service developments. We identified that there are spread sheets

identifying the impact of nursing principles for each ward and this has been incorporated into the funded nursing establishment.

However, there was a low level of awareness of the establishment and skill mix agreed for each ward as a result of the nursing principles. This had not been seen

by the senior staff responsible for putting the rosters together. On seeing the skill mix requirements a number of the Ward Sisters were not happy for their staff to

be working in those conditions. The Sister on Llewellyn Ward, Bronllys voiced her concern for staff to be working in such conditions especially as her ward has

single bays which makes nursing coverage slightly difficult on times compared to a six bedded ward. The Ward Sister on Epynt and Y Bannau Wards in Brecon

War Memorial Hospital also voiced similar concerns especially as both wards have very high patient dependency.

Maternity Services

Maternity services use Birth Rate Plus acuity tool. The acuity tool is endorsed by

Welsh Government. The staffing establishments are formally reviewed every

three years.

Estates

There was no agreed skill mix or establishment listing, detailing the required number of staff required to meet service needs, for the Estates Department,



Appendix A



Bronllys. Staffing budgets are based on previous years’ activity. No evidence was provided to confirm that a review of staffing levels has been carried out.

Assurance can therefore not be given as to whether there are sufficient or insufficient numbers of staff working in this department relative to their

workload. Please also see finding 4 which provides further information relating to Estates where we were unable to undertake any meaningful testing on

timesheets relating to Estates Staff.

Catering

No establishment list could be provided for Catering at Bronllys Hospital. The

current skill mix requires a total of 195 hours to be worked each week. Based on the current staff available and assuming that there is no holiday or sickness

absence there are 199.5 hours available. The current staff mix requires 4 staff on during the lunchtime period. Some assurance is needed to confirm that

staffing levels being utilised are required based on current workload.


The establishment and skill mix for Wards should be reviewed on an annual basis

and agreed with the Senior Nurse/Ward Manager responsible for planning the roster so that the ward can operate safely. Any deviations from the Nursing

Principles should be documented e.g. – high dependence of patients. The wards highlighted should be reviewed (Llewellyn Ward, Bronllys Hospital, Epynt and Y

Bannau Wards, Brecon War Memorial Hospital). All other departments/services should review their establishment and this should

be reviewed at least annually or as and when individuals leave the employment of the Health Board. The establishment should be clearly linked to the work profile

and needs of that service. This needs to be undertaken urgently for Estates and Catering at Bronllys Hospital.

High



Appendix A




Nursing

Establishments and skill mix reviewed and agreed at least annually between

Senior Nurses, Lead Nurses and Deputy Director of Nursing. Additional funding from Francis work has been agreed to ensure optimum staffing. Staffing

requirements also reviewed daily by Senior Sisters to flex in accordance with ward needs and any concerns escalated to Senior Nurse. Any shifts of concern

in relation to staffing are reported using Datix – and are reported by any Nurse

on the ward whenever appropriate. Budget meetings also used to review skill mix & current establishment.

Ward establishments will be reviewed monthly and deficits reported to the Workforce and OD committee bi-monthly. The Establishment will be

triangulated with quality information and metrics to provide assurance as to safe staffing data.

Catering Bronllys

This is a historic roster pattern. As noted in report, there is not a sufficient

establishment to allow cover for annual leave and sickness with current roster pattern. Action: Kitchen rota and hours to be reviewed by Head of Facilities and

any recommended changes to the skill mix/establishment actioned.


April 2015

Business Development Manager & Head of Facilities. Review to be

completed by 1st June 2015



Appendix A



Finding 3 Impact

Rostering for Wards (Operation)

Rosters in respect of 5 hospital wards across Powys were examined. We noted a number of localised systems operating e.g. Self Rostering at Machynlleth Hospital

and Rostering at Brecon Hospital (based on requests).

We identified that rosters are created 4-6 weeks in advance, however there was

no evidence to identify that the Rostering Manager is monitoring and approving

the rosters on completion.

None of the staff we spoke to who have responsibility for the preparation of

rosters had received any form of training in terms of rules that should be adhered to and the efficient and effective use and deployment of staff.

Preparation of the roster was normally found to be the responsibility of one officer who subsequently held a substantial amount of local knowledge which was not

always documented. It would therefore be difficult to ensure continuity in the event that this officer was to leave.

The overall presentation of rosters was found to be very poor and hard to follow, this was generally as a direct result of the number of amendments made after

the roster had been completed. As the Ward Sisters had no roster template to follow, they created the rosters in a way which suited them.

Old rosters were retained for reference and discussions with staff would suggest that they are kept in perpetuity. However, discussions with the Ward Clerk for

Llewellyn Ward identified that these rosters are only kept for 2 years before they

Illegible rosters do not facilitate the

checking of timesheets. Errors may go unidentified.

Equity in the allocation of shifts cannot be demonstrated.

Without documented processes

continuity cannot take place when key officers leave.

Effective collection of data for the reporting of Health Board Key

Performance Indicators cannot be carried out.



Appendix A



are destroyed. Before being destroyed these are not stored securely. Assurance can therefore not be given that they have not been tampered with or altered

after a shift has taken place. Whilst this would be immediately apparent for current rotas this would not be the case for historic rosters. In the event of a

formal enquiry, it is unlikely that this information could be used as evidence.

A number of local arrangements were found to be operating in various wards e.g.

staff would work shorter shifts (Llanidloes) and every other week (Machynlleth).

As different practices are operating at each of the locations tested there would appear to be some disparity in respect of the deployment of staff with some areas

appearing to be more favourable than others.

Testing was carried out on shifts relating to 59 Rosters covering the period April to September 2014. We identified the following:

There were 32 instances where overstaffing was recorded as having taken

place. This was found to have occurred on all wards tested. The majority of instances related to shifts where skilled nurses were not available and

unskilled staff were being used. Other occurrences of apparent overstaffing were found to be as a result of additional resources being required which

were not identifiable on the roster e.g. clinics at Machynlleth and escort duty at Llanidloes.

There were 7 instances where the Roster was understaffed; Twymyn Ward,

Machynlleth, 1 night shift. Epynt Ward, Brecon War Memorial Hospital, 5 shifts and Y Bannau Ward, Brecon War Memorial Hospital 1 shift.

There were 3 instances where the Roster were not clear.

Overstaffing, in the majority of instances was found to occur as a result of

insufficient skilled staff being available. On these occasions a higher number of HCSW’s were brought in to compensate. Examples of this would include Llewellyn



Appendix A



Ward, Bronllys, where all ten shifts tested were found to have a higher number of staff working than recorded on the Nursing Principles. Seven of the fifteen

shifts selected for testing on Epynt Ward were also found to have a higher number of staff working when compared to the Nursing Principles. Overstaffing was also

found to occur where Self Rostering was in operation. On these occasions the Ward Sister, Twymn Ward, Machynlleth, indicated that she would request staff to

carry out mandatory training. The option of requesting staff to take leave was

not applied.

The Audit Review carried out additional testing on 120 rosters (a larger sample

was used for this test) where hours recorded on timesheets were compared

against hours recorded on the roster; 16 exceptions were noted. Whilst explanations were given for the majority of these, these could not be followed

through due to the manual nature in the preparation of the records. Enquiries identified the exceptions to be as a result of local arrangements operating e.g.

Llanidloes where shorter shifts are worked by a number of staff but these are not clearly identified on the Roster, the hours were being recorded on the timesheets.


Current practice does not comply with the draft rostering policy that is currently

in place. Once this policy is agreed then staff need the appropriate training and development to understand their responsibilities in relation to this key policy.

The current practice of “local arrangements” may need to be preserved to some degree to reflect the resourcing difficulties in certain localities, however all areas

High



Appendix A



need to operate to a common minimum standard when rostering. This would then assist the implementation of an e-rostering system.

Rosters should be appropriately approved by a Senior Nurse/Budget Holder.

Rosters should be retained in a safe place for 4 years.




Appendix A



The roll out and training programme associated with the roster policy will be

targeted to address the issues identified within the audit findings.

The PtHB draft Policy Rostering will be re-issued immediately with compliance

requirements reinforced.

Rostering Awareness Sessions will be delivered for all Sisters/Charge Nurses and

Senior Nurses.

Senior Nurses will sign off all nursing rosters monthly.


Assistant Director of Nursing

July 2015 Assistant Director of Nursing DON May 2015 ADON July 2015 Lead Nurse May 2015

Finding 4 Impact

In addition the Health Board will implement E-Rostering during 2015/16

focusing on the high risk areas identified in this report in the first instance.



Appendix A



Rostering for Estates, Bronllys Hospital (Operation)

Rosters are not drawn up for staff working in Estates. Officers work standard

hours. Following discussions with Supervisors and the Interim Head of Estates for Maintenance Operations, it was confirmed that records detailing the

whereabouts of officers and work carried out by them could not be relied upon. This was as a result of records e.g. job sheets which were not fully completed

and were not checked by Supervisors before being signed off. Furthermore, there

were no records available for testing for the period April – September 2014. It can therefore be concluded that that there is no management control operating.

This was confirmed by the Interim Head of Estates for Maintenance Operations. It is understood that systems resulting in the maintenance of records were in the

process of being introduced following the initial audit visit.

Assurance cannot be given that for the time frame examined April – September

2014 that the workforce was operating in an efficient or effective manner. Assurance cannot be given that staff actually turned up to work.

The only area which was capable of being tested related to “out of hours” where additional payments are made to the estates staff based on additional work

requiring immediate action out of normal working hours. Payment for “out of hours” work is made following submission of an authorised timesheet. Testing

of five jobs identified that these were not actually on the Integrated Facilities Management System (IFM System). Timesheets had been signed but we have no

evidence that these were verified and there is no evidence to demonstrate that

management questioned that these jobs were not recorded on IFM.

Managers are unable to verify that

timesheets submitted are accurate.

Poor utilisation of resources

Inaccurate recording of time worked.



Appendix A




A full management review of all activities relating to the management of estates should be carried out as a matter of urgency. Improvements need to be made in

general record keeping to demonstrate compliance with policies and procedures. Management control needs to be applied.


High



Appendix A



The ability to match demand and capacity is dependant upon understanding

demand in the first instance. The Estates Department is split into two sections: Capital Projects and Maintenance and Minor Works. The finding and

recommendation noted above apply specifically to the Maintenance and Minor Works Section and this response reflects this. Capital Projects staffing is based

upon the Project Management requirements of each project and is

accommodated within each Project plan and costs.

A new Head of Estates and Property was appointed on 23rd March 2015, and revised management and governance arrangements were implemented from 1st

March 2015 via an Estates Management Team (meeting weekly) an Operational Estates Team (meeting monthly) and an Estates Compliance Committee

(meeting monthly)

The Maintenance and Minor Works Section will: 1. Undertake site based asset condition surveys in order to develop a Planned

Preventative Maintenance Programme 2. Clarify the workforce requirements to deliver this Programme

3. Quantify predicted demand for reactive maintenance work 4. Clarify the workforce requirements to deliver this

5. Produce an annual Staffing Plan based on the above steps

6. Introduce a monthly Performance Report that includes hours available v hours used

7. Ensure that Job cards include travelling time and job completion times to ensure that the Integrated Facilities Management system can be used to

monitor staff deployment and inform the annual Staffing Plan

Head of Estates and Property 1. By 30th June 2015

2. By 31st July 2015 3. By 31st July 2015

4. By 31st July 2015 5. 30th September 2015 to be

updated annually in January

each year) 6. From 1st April 2015

From 1st April 2015



Appendix A



Finding 5 Impact

Rostering for Catering, Bronllys Hospital (Operation)

20 Rosters, covering the period April to September 2014 were selected for

testing. The date of completion of the roster is not detailed and whilst assurance was given that rosters are normally prepared at least six weeks in advance this

could not be evidenced.

Rosters should be prepared by the Domestic Supervisor, but currently they are

being created by the Lead Cook. Assurances cannot be provided that the rosters

are prepared fairly and take into account the wishes of all employees. The rosters are not authorised by the line manager.

Equity in the allocation of shifts

cannot be demonstrated.


Rosters should be prepared by an appropriate individual and these should be approved by the budget holder/authorised signatory to demonstrate that these

have been drawn up in a fair and equitable manner.

High



Appendix A




This point is noted and further work will be undertaken to ensure correct policies and procedures are undertaken. The role out of the roster policy and training will further support the reinforcement of the correct approach.

Head of Corporate HR Practice and

Development

July 2015

Agency Nursing Services

Finding 6 Impact

Approval of Locum and Agency Staff (Operation)

In the areas tested, the use of Agency staff was not prevalent (Twymyn Ward Machynlleth and Brecon War Memorial Hospital). At the time of the audit, the

Health Board had spent £326k on Agency staff (April 2014 – October 2014). Our audit testing identified that this policy is not being applied consistently.

Prior to the booking of Agency Staff written authorisation must be obtained from the Locality General Manager or Director on Call.

Agency staff were noted as having been used at Machynlleth Hospital. On this occasion Agency staff were brought in to provide cover for a high dependency

patient. Auditors were assured that the correct processes were followed; however

evidence to confirm this was not provided.

Agency staff are booked without the

appropriate authorisation resulting in a breach of standing orders.

Agencies are being used which are not on the framework contract and

therefore have not been through appropriate checks which poses

risks to the Health Board in terms of lack of key assurance requirements.



Appendix A



At Brecon Hospital; Epynt and Y Bannau Wards, Agency staff were noted as being used. The Ward Sister confirmed that she had not gone through the relevant

processes i.e. confirmation from Director due to the urgency of the situations for which they were needed. Retrospective authority was not obtained.

It is unclear why the particular agencies used were selected. The Agencies used in testing were Thornbury Nursing Services Ltd and CLCA Co Ltd. Neither of these

Agencies are on the framework for Agency Nursing Services. The All Wales

contract expired on 30/09/2014. A new contract will commence on 1 March 2015 (the award recommendation is currently with the Health Minister).

After an initial short transition period, we understand that there will be a co-ordinated drive to ensure that all future agency activity is only against the new

contract (which will not include Thornbury Nursing Services Ltd or other premium rate agencies).

The Policy and Procedure for the Approval of Locum and Agency Staff states that “PtHB will contract to one agency per discipline and obtain a written undertaking

that any staff used will have an up to date Criminal Records Bureau check at the appropriate level identified and/or registration with the Independent

Safeguarding Authority (ISA) as required by law, current professional registration and employment references. This will be in line with the All Wales Guidelines

“Contract Specification for the use of Agency Staff”.

We have been informed that no Agencies on the previous contract provide

services to Mid Wales despite contract documentation which shows that there

were 8 agencies that provided these services on an All Wales basis. Clarification in respect of the use of Agency Staff by the Health Board is currently being sought

from the Head of Procurement, Shared Services.



Appendix A



As the Agencies used are not on the framework, they would not have been taken through any pre-qualification checks. This highlights at least two fundamental

issues:

1) The Health Board is breaching Standing Financial Instructions. The Health

Board is incurring expenditure with a supplier which has not been formally tendered as they opted out of the All Wales Procurement Process. As far as

we can ascertain there is no contract in place between the Health Board and

the Agency.

2) Any agencies that submit a tender offer for the All Wales Contract go through

a vetting process by Procurement Services. This would cover the following (initially and on an on-going basis):

Confirmation that Agency workers have appropriate Disclosure Barring Service (DBS) check including POCAL and POVAL lists;

Agency workers supplied are able to demonstrate their clinical competence, qualifications and skills to meet the Health Boards’

needs;

Agency workers have current registration and continue to provide

evidence of continued eligibility to practice;

Agency workers who are not British Citizens or EC nationals and who

have not been granted permanent status in the UK have the necessary Home Office permission to work;

Agency workers who have entered the UK within the previous 6

months prior to recruitment shall ensure that a police check has been undertaken within the previous 3 month period from the date of

recruitment with their country of origin;



Appendix A



Agency workers’ references have been checked;

Agency workers have undergone comprehensive health screening by

a competent Occupational Health Service;

Agency workers have current immunisations (Hepatitis B, Measles,

Mumps, Rubella, Tuberculosis, Varicella);

Agency workers have demonstrated negative results for Hepatitis B,

Hepatitis C and HIV.;

Agency workers adhere to Health Board policies and procedures including those relating to fire, information security, manual handling

and health and safety;

Agency worker has informed suppliers of investigations, subject to

cautions, reprimands or prosecution by the police after a DBS check was undertaken;

Agency worker has been under investigation by their own professional body;

Agency worker has been under investigation by NHS Counter Fraud Services;

Agency worker has undertaken relevant training and development; and

Agency workers receive appraisal and individual performance monitoring.



Appendix A




The Policy and Procedure for the approval of Locum and Agency Staff must be complied with and non-compliance must be addressed.

The Health Board should put in place a contract with any agencies used not on the framework contract. Appropriate vetting of the Supplier to address potential

workforce and quality risks should be undertaken.


A new policy will be implemented for Locum Staff and Agency Staff. Further

training in this area will also be completed. The all Wales framework is currently being developed for nursing and the Health Board will ensure compliance with

this framework. A meeting is currently being established to address any agencies which are outside this framework.


Development

Assistant Director of Nursing

June 2015

High



Appendix A



Bank Staff

Finding 7 Impact

Lack of effective system for the deployment of Bank Staff (Operation)

Inconsistencies in the application of the policy and the use of Bank Staff were

identified.

Ward staff responsible for the booking of Bank Staff commented that the majority

of their time is spent trying to obtain Bank Staff to fill a vacant shift. On some

occasions time is wasted because Bank Staff are unable to be contacted due to out to date lists or they are unavailable for work because of other commitments

e.g. a Ward Sister spent 5 hours contacting people on the Bank to cover a shift due to illness.

Lists detailing the contact details of bank staff appeared to date back some time (“tatty” with several crossings out on). Lists seen did not record the availability

or otherwise of staff e.g. whether they had substantive posts and were therefore unavailable for specific shifts. Minimal data/evidence was retained to confirm

which Bank Staff had been contacted, how many times and when. As identified during testing carried out on rostering a significant amount of “intelligence” is

retained informally and not documented.

Examination of the current database detailing all Bank Staff noted a large number

of names who have not worked for the Health Board for at least two years.

Inconsistent practices leads to Bank Staff not being deployed in a fair,

efficient or effective manner.

Poor use of Ward Sister time as a

consequence of out of date records /lists for Bank Staff.



Appendix A



It is understood that work is currently being undertaken, by the Assistant Director of Workforce & OD to produce an up to date list which will be held on a central

drive and available for all appropriate officers to view.

One instance was noted (Llewellyn Ward) where the individual responsible for

preparing the roster was also registered on the Bank. There were occasions where she booked herself as a Bank Staff member to cover shifts on her ward.

There is therefore no segregation of duties, and even if this was permissible there

is no authorisation by the Line Manager to evidence that this practice is known and accepted.


The database detailing all available Bank Staff should be completed as a matter

of urgency. Consideration should be given to including details of availability for work and specific times which cannot be considered. This will ensure unnecessary

time is not spent trying to fill shifts.

Where staff are in effect booking themselves as bank staff additional controls should be put in place.

High



Appendix A




New Bank Policy to be implemented with the introduction of the bank database

in the interim period. However as part of the purchase of an e-rostering system, the Health Board will seek to procure a commercial e-rostering system to ensure

the improved control management and utilisation of bank staff in line with roster requirements.

Whilst a new Bank Policy is in development controls will be put in place for the verification and authorisation of Bank at a local level.

Assistant Director of W&OD


Development


July 2015 for policy July 2015-2016 for bank systems. Assistant Director of Nursing May 2015



Appendix A



Finding 8 Impact

Training of Bank Staff (Operation)

Responsibility for ensuring that Bank Staff are up to date in terms of Statutory

and Mandatory training rests with the recruiting manager (normally the Ward Sister).

Testing identified at least half the names on the Bank Staff database had not

received mandatory training. It is acknowledged that the database is currently being reviewed and where appropriate errors and anomalies are being

investigated. Of the 661 names on the database and after manually discarding duplicate names a total of 349 bank staff were identified as not having had

mandatory training. Discussions with staff working in HR have identified that there may be a possible “glitch” between the system recording the training and

the database.

Examination of the list would also indicate that the majority of Bank Staff have

not received corporate induction.

Ward Sisters and Line Managers were not sure where responsibility rested for

ensuring that mandatory training and corporate induction was carried out. No evidence was provided to confirm that PADR’s are carried out.

Staff without the required/necessary skills training

are working for the Health Board.


The Health Board must decide which system it wishes to maintain for the

purposes of maintain statutory and mandatory training records.

Line Managers must ensure that all Bank Staff are up to date with their training.

High



Appendix A




The new Bank Policy when implemented outlines the responsibility for recording

and maintaining training and PADR’s. The core system for recording of all training will be via the ESR.

An improvement plan for the management of the bank will be developed in line with the introduction of the electronic bank system.


Development Assistant Director of Nursing

Commencing July 2015



Appendix A



Finding 9 Impact

Recruitment of Bank Staff (Operation)

During the course of the audit, reference was made on a number of occasions to the length of time taken by HR to complete the recruitment process. Detailed

discussion with HR and an examination of the process was carried out. The recruitment process is carried out by NWSSP following receipt of a completed

Workforce Approval Form from HR.

Two locations were selected where Bank Staff have been recruited; Brecon and

Newtown.

Brecon: 070-ACS011-0314. The appointment form was forwarded to NWSSP

28/03/14. Information allowing short listing to take place was made available 16/04/14. Interviews however, were not set until 12/05/14, one month later.

Interview dates are set by the Recruiting Manager (in this case the Ward Sister). 29 appointment letters were sent out 20/05/14. To date there are still applicants

who have not returned the relevant documentation to enable their posts to be

confirmed e.g. references, completed occupational health forms. It is not the responsibility of HR or NWSSP to chase outstanding queries.

Newtown: 070-NMR034-0514. The appointment form was forwarded to NWSSP 6/5/14. Interviews were held 4/6/14 where all 5 applicants who were invited to

interview were offered the post of Bank Nurse. To date three nurses have started and further information is required from the other two.

The process of recruitment takes so

long that applicants have found alternative jobs by the time they are

offered the post.

Shifts are unfilled which could have

been avoided if recruitment and appointment of Bank Staff was

expedited.



Appendix A



The above testing confirms that the overall appointment process is not a particularly fast process. However, at Brecon the overall process could have been

hastened if interview dates had been agreed earlier.


Recruiting Managers (e.g. Ward Sisters) need to be reminded that they are to expedite the process by setting interview dates and chasing up applicants for

references and other appropriate information.


Guidance for recruiting managers is available on the intranet. All recruiting managers will be reminded of this via email and key business meetings.


Development

June 2015

Medium



Appendix A



Finding 10 Impact

Accuracy of Bank Staff Timesheets (Operation)

60 records were examined where timesheets for Bank Staff were matched to rosters. 8 differences were identified, these are as follows:

Epynt (Brecon War Memorial Hospital) - 12 records tested, differences

noted on 2 records; On both occasions the difference was less than half an

hour. Y Bannau (Brecon War Memorial Hospital) - 8 records tested,

differences noted on 2 records; a difference of two hours being noted on one of these records. One timesheet could not be located;

Graham Davies (Llandidloes) – 15 records tested - hours for two were not recorded on roster and timesheet not available for one. Possible reason

for this was given as Escort Duty; and Machynlleth – 10 records tested; differences noted on 2 records - 5 hours

were recorded on the timesheet, however the roster stated 6.5 hours worked and 11.25 hours on the roster, however 12 hours recorded on

timesheet. It is understood that a short break was taken on this shift.

As the Rosters were not correctly updated when shorter/longer shifts were being worked the integrity of the staff has to be relied upon when recording actual

hours worked.

Hours are being paid which have not

been worked.



Appendix A



We tested ten records in Llewellyn Ward, Bronllys Hospital and we did not identify any differences. All 5 records tested in Catering, Bronllys were correct and no

inconsistencies were identified. No Bank Staff were used in Estates, Bronllys.

Machynlleth was the only establishment noted where bank timesheets were fully

completed with the reason for using bank staff was recorded.


Where timesheets record hours that are different to those scheduled on the roster, a record should be maintained to identify the reason for the difference.

Reasons for using Bank Staff e.g. maternity leave/sickness should also be

recorded on all occasions.


Implementation of Roster Policy and managers will be reminded to complete the Bank timesheet correctly to state reason for cover via written communication.

A process for scrutiny will be introduced.


Deputy Director of Nursing July 2015 Assistant Director of Nursing July 2015

Medium



Appendix A



Overtime/TOIL

Finding 11 Impact

Application of Overtime and Hours Over Contract Policy and Procedure

(Operation)

Overtime

This policy is up to date. However, testing identified that the Policy is not being applied correctly. The overtime authorisation process is not being followed or

completed.

Our testing identified that in Catering Department, Bronllys Hospital overtime is

being applied without the appropriate authorisation and without using the escalation process as set out in the Overtime Policy. There is no assurance as to

whether overtime is being offered in a fair and equitable manner to all staff. The officer responsible for putting the roster together was noted as having the highest

TOIL is often not authorised and

when it is documented it can be very ambiguous.

TOIL may be taken before it is accrued.

Inconsistent application of the policy may result in more favourable

conditions of employment for certain individuals employed by the

Health Board.



Appendix A



level of overtime. The payment of overtime appears to be planned each week with no authorisation being required.

Overtime was identified at Brecon War Memorial Hospital; Y Bannau and Epynt Wards. Confirmation was provided by staff that no authorisation had been

obtained and therefore the Policy had not been applied correctly. Reports produced by Payroll state that overtime costs for the period April to September

2014 were £572.

Overtime was also identified at Machynlleth. Whilst verbal assurance was given that the appropriate authorisation was obtained formal evidence of this was not

provided. Reports produced by Payroll state that overtime costs for the period April to September were £720.

TOIL

The Overtime policy details how TOIL should be applied. 40 records of TOIL were

tested and Several different methods of recording TOIL were identified during the course of the audit, none of these were in accordance with the policy.

Wards: The records tested were poor and in some cases there were no records maintained. Authorisation was not always obtained either in respect of accruing

the time or taking it. There were a large number of instances where TOIL had not been used for a lengthy period of time, certainly more than two months. It

was also noted at Machynlleth Hospital that TOIL was being noted on timesheets and then being paid. TOIL is being paid at overtime rates where it is in excess of

37.5 hours, this is in effect overtime.

On Llewellyn Ward a TOIL record is maintained. There is an informal arrangement in place that when TOIL is accrued it should be recorded together with the date

it is intended that this time will be taken. It was not clear whether TOIL had been authorised as having been taken or not.



Appendix A



On Epynt and Y Bannau Wards, Brecon War Memorial Hospital, two record books are maintained. Samples of ten records were selected. High Levels of TOIL were

identified. A significant number of these were over three months old (TOIL should be used within three months, if for operational reasons this time cannot

be taken within three months it must be paid at overtime rate).

Twymyn Ward, Machynlleth Hospital, extra hours are recorded on the bottom of

the timesheet. No separate record is maintained. At the time of the audit the

Ward Sister had accrued 115 hours of toil, this was converted to additional time. It is understood that this has been paid as plain time.

Graham Davies, Llanidloes, poor record keeping was noted with high levels of TOIL being accrued which had not always been authorised. Of the ten records

examined, authorisation for 5 could not be identified. 4 of the ten records tested had toil in excess of 20 hours.

Midwifery: A basic standby payment of £18 is paid and hours are recorded on the timesheet as standard contract hours of 7.5 hours. The Midwife is on call at

home and will only claim hours if she is called out to a birth. If she is not called out then she will be minus 7.5 hours on her toil record. A record of TOIL is kept

in a diary which is retained in the office. On a monthly basis all figures are collated together and a central record is reviewed by the Manager. Examination of this

spread sheet noted some high levels of TOIL owing. It was explained that if a Midwife went over 15 hours then the work diary and work sheets would be

reviewed to check the workload and the reasons why there are so many hours.

As at October 2014 at least one member of staff had hours owing in excess of 53. Members of staff should not be allowed to create this level of time owed.

Estates: No formal records of TOIL were maintained for the period April – September 2014. TOIL would be accrued and taken without any authorisation.



Appendix A



Managers confirmed that they were unable to control time taken off in this manner. It is understood that systems are in the process of being implemented

to address this issue.


All staff should be reminded that there is an Overtime and Hours over Contract Policy and Procedure which should be adhered to. The current position within

Catering should be reviewed as a matter of urgency.

In accordance with the policy all TOIL should be approved before it is accrued

and also when it is taken. TOIL should be taken within three months of being

accrued. All records detailing TOIL accrued and taken should be retained for audit purposes.

The current practice operating within Midwifery has not been formally documented or approved by Board or Executive. Whilst it is understood that

lengthy discussions have taken place with Human Resources regarding alternative methods of staff accruing hours whilst on stand-by, no feasible

options have been agreed. The current practice operating within Midwifery should be revisited and re-examined to identify alternative working practices resulting

in high levels of hours being owed.

If accepted, the practice within Midwifery of being on standby and accruing TOIL

should be documented so that all staff are fully aware of how it operates.

Any non-compliance should be identified and the individuals targeted for training

or education. Any continued non-compliance should be addressed through the PADR process.


High



Appendix A



Managers will be reminded of the Overtime and Hours over contract policy and

procedure.

Maternity

Time in lieu is regularly reviewed and records kept for all midwives. The balances

fluctuate based on the amount of call outs the midwife undertakes, T/L has to be agreed by Lead Midwife. The system in place is to protect Midwives so they

aren’t working excessive hours – if Midwives worked all day and then were on call and called out we would then be in breach of working time directives and not

have staff available to provide care during an on call period. The decision process regarding how the midwifery workforce hours are managed

was agreed when the move was made from a GP led service to a midwife led service in 2001.

To ensure 24 hour service coverage there are no other options that have been explored that do not equate to either a significant increase in midwifery numbers

which would be out with the Birthrate plus calculations or the closing of aspects of the service.

Staff are aware of how the system works. Lead midwives are robust in challenging and reviewing hours. It is however entirely possible for a midwife to

accrue a substantial amount of T/L in one month if called out on several on calls,

whilst in another month they may not be called at all. Maternity services are not in a position to plan the activity that impacts most on out of hours.


Development May 2015 Lead Midwife May 2014



Appendix A



Finding 12 Impact

Delivery of Contracted Hours (Operation)

Testing was carried out in respect of 120 shifts worked where hours recorded on

timesheets were compared to hours stated on the Rosters. Where possible the anomalies were discussed with the appropriate officer. The differences identified

were as follows:

Llewellyn Ward, Bronllys – 20 tested – 5 differences; i) Longer shift worked

(11.25 hours) recorded on roster as 7.5 hours; ii) Days worked recorded incorrectly on timesheet, standard contract hours of 37.5 worked for

week.; iii) Phased return to work not detailed on roster; iv) extra 0.25 hours worked, not recorded on roster; v) shorter shift, not recorded on

roster. Epynt, Brecon War Memorial Hospital – 20 tested – 2 sheets not available

+ 2 differences; i) 7 hours recorded on roster, 7.5 hours on timesheet; ii) 11.5 hours on roster, 4.25 hours on timesheet.

Y Bannau, Brecon War Memorial Hospital – 20 tested – 1 difference identified where due to the number of amendments made hours worked

were not legible; and Llanidloes – 20 tested – 5 differences noted, however 4 of these related to

local arrangements. Therefore 1 difference; the roster recorded a full week

working, however the timesheet had not been fully completed.

The local arrangements operating on the Graham Davies Ward, Llanidloes related

to shorter shifts being worked; the arrangement having been agreed at a local level. Overall there was a 91% accuracy rate. All timesheets tested in Catering,

Bronllys and Machynlleth (20 in each Department) identified no inconsistencies.

The current manual system of preparing rosters does not easily

identify where contracted hours have not been fully utilised.

Hours are being paid which have not

been worked.



Appendix A



Standard contract hours are paid regardless of whether they have been worked. Timesheets are submitted in order that the enhanced payments can be made.

Testing was attempted to be carried out to ascertain whether standard hours had been worked and how this was recorded. Inconsistent methods of recording this

data were noted. No evidence was noted, other than the signing of timesheets where applicable, that hours claimed by staff are actually worked.

The current method of rostering does not provide a readily available picture

confirming whether contracted hours have been worked. The process of verifying this is very laborious and time consuming.


Officers who are responsible for signing timesheets need to be reminded that

hours on timesheets must reflect those on the roster. Where there is a difference, this should be recorded.


Implementation of Roster Policy and subsequent training roll out plan will target the issues identified.


Deputy Director of Nursing July 2015

Medium



Appendix A



Finding 13 Impact

Professional Nursing & Midwifery Standards (Design & Operation)

During the course of the audit review, reference was made to Datix reporting and the Safety Cross System whereby a pictorial record is completed each day. A

grading system is applied Green – Red depending upon the final outcome. Evidence in the form of an email sent to all ward sisters was seen

detailing the procedure which should be followed when reporting a risk. It is unclear whether this email has been distributed to all appropriate staff.

In the absence of a published policy on Professional Nursing and Midwifery

Staffing Standards, assurance cannot be given that all staff are aware of the procedures to follow in the event of an identified shortfall in staff which may

affect the safety of patients.

The process for raising Datix reports was discussed with the Locality Lead Nurse

(North), who felt that too many reports were being raised after the event and without the relevant detail confirming that appropriate action had been taken.

Examination of the Datix Report relating to the period April – September 2014 noted 13 instances where Datix reports had been submitted in respect of staffing

which was below the prescribed skill mix (5 in Y Bannau and Epynt Wards in Brecon War Memorial Hospital, 5 instances in Twymn Ward, Machynlleth and 3

instances in Llewellyn Ward, Bronllys.)

Of the 7 instances identified by Internal Audit testing where shifts were

understaffed, none of these had been reported on Datix. Internal Audit were informed that this situation might not always result in a Datix report being

generated. This would only take place if the Ward Sister thought that the staffing

Staff may not be aware of the

correct procedures to follow. Inconsistent practices will develop

with localised practices developing.

Wards could be operating in an

unsafe staffing situation.



Appendix A



levels were at a level that could compromise patient care. This would only take place if the Ward Sister thought that the staffing levels were at a level that could

compromise patient care. We encountered differing views on the process to follow, and therefore the Policy needs clarification so that there is no

misunderstanding.

The Policy states:

“DATIX

This is the system by which reported staffing issues will be graded: Green

There was no reported concern or compromise to patient care or safety due to the available staffing in an area

Amber There is a reported concern over the available level of staff.

This report has been investigated and the outcome was: There was no compromise to patient care or safety

OR There was limited compromise to patient care but this did not impact on

the patients required interventions (medication, observation input or output), progress, outcomes, or dignity

Red There is a reported concern over the available level of staff.

This report has been investigated and the outcome was:

There was a compromise to patient care or safety.”

The Policy could be interpreted to mean that a Datix incident should be completed

where there is concern over the available level of staff, and once investigated if there was no impact to patient care or safety – this is recorded in Datix. This

would appear to contradict what we have been told by Health Board staff.



Appendix A



Further work is currently being undertaken, by HR where all Datix reports which relate to staffing concerns on the wards are being analysed and examined to

establish what action has been taken.


The Policy should be issued as final, and communicated to all relevant staff across the Health Board.

Where wards have the incorrect skill mix or staff numbers as per the Nursing Principles documentary evidence should be retained to identify what action has

taken place.


Implementation of Professional Nursing & Midwifery Staffing Standards will be prioritised in all areas.

All Sisters and Charge Nurses will be reminded of the shifts of concern procedure.

All shifts tat are non-compliant to establishment/AWNP will be reported via Datix.


May 2015 ADON May 2015

High



Appendix A



Working Time Directive

Finding 14 Impact

Working Time Regulations Policy and Procedures (Operation)

All staff were aware of this procedure in respect of the number of hours they

were permitted to work. However, it was noted that on frequent occasions in many of the wards visited e.g. Llanidloes and Machynlleth breaks were not being

taken overnight and compensatory rest was being given. Compensatory rest appears to be applied consistently and in many cases appears to be the norm i.e.

expected. Working Time Directive should not be applied in this manner. On frequent occasions the time accrued was not being taken back within 2 weeks.

Discussions with staff working in Human Resources identified that periodic checks are carried out to ensure that the Working Time Directive is not exceeded in

terms of hours worked for staff who also work bank shifts. However, the onus is on Managers to check that staff are not breaching this regulation through the

hours worked whilst on the Bank.

The European Working Time

Directive is not being complied with.




Appendix A



Breaks should always be taken and only in exceptional circumstances should staff go without a break during a shift.

Where substantive staff are also Bank Staff additional controls should be introduced to ensure that the Working Time Directive is not exceeded.


Monthly reports will be run by workforce and organisational development to ensure the working time directive is not exceeded.

Sisters/Charge Nurses will be reminded of the EWTD and the rules regarding breaks.

Workforce Intelligence & Systems Lead

May 2015

ADON May 2015

High



Appendix A



Attendance Management

Finding 15 Impact

Application of All Wales Sickness Absence Policy (Operation)

All staff spoken to during the course of the audit were aware of this policy. We identified that the initial contact is not being recorded per the All Wales Sickness

& Management toolkit which states the responsibilities of the individual and Line

Manager. For all sickness absence the following should be confirmed without exception:

- Nature of the illness – relates to accident in work or illness which may have

an impact on other staff (e.g. Sickness & diarrhoea); - The likely date of return; and

The All Wales Sickness policy is not

being adhered to, sickness is not being monitored well.



Appendix A



- When contact will be maintained – this should be 2 way and always maintained.

The initial record of contact is essential especially if the Line Manager is not in work due to holiday or sickness, as it means that from a continuity perspective

there are adequate records for an alternative Manager to deal with the situation.

We tested 43 records, 23 records for short term sickness, 15 records for long

term sickness and 5 records for 3+ triggers. Our findings are as follows:

Short term Long term findings:

There is an All Wales Sickness Policy and an accompanying All Wales Sickness

Management toolkit.

Short Term Sickness

Wards – when someone rings in sick a red “S” is put on the roster if they are down to work the shift. There is no other information obtained to support the

sickness. Sick notes are obtained when applicable. A record of initial contact would log all this information. Out of the 23 sickness records we looked at; 15

instances had no record of the initial contact made by staff to notify the sickness instances, 6 instances had no back to work interviews completed and 2 instances

where no records could be found. Our testing showed the following:

- 10 records were tested in Bronllys (7 on Llewellyn Ward, 2 in Domestic

services and 1 in Estates) – No point of contact forms had been filled in, 1 back to work interview had not been completed, and 2 records could not

be found.

- 6 records were tested on Y Bannau and Epynt Wards in Brecon War Memorial Hospital – 1 out of 6 point of contact forms were not completed

and 3 out of 6 back to work interviews were not completed.



Appendix A



- 3 records were tested on Twymyn Ward, Machynlleth Hospital and no point of contact forms or back to work interviews had been completed.

- 1 record was tested for Midwifery and only the back to work interview had been completed.

- 3 records were tested on Graham Davies Ward, Llanidloes Hospital and all documentation was completed.

Discussions with Ward Sisters confirmed that back to work interviews have

deterred employees from taking unnecessary sickness. All sick notes and self-certification forms are being kept on personnel files and ESR.

Long Term Sickness

We tested 15 records for Long Term Sickness; 9 records in Brecon War Memorial Hospital (Epynt and Y Bannau Wards), 3 records in Bronllys (1 in Llewellyn Ward,

1 in Domestics and 1 in Estates), 2 in Llanidloes Hospital (Graham Davies ward) and 1 in Midwifery.

Out of the 15 records we tested; 11 records had all the necessary sickness documentation required. We were unable to view the remaining 4 records at

Brecon War Memorial Hospital. Two members of staff had left the organisation and their personnel records were not available on site, 1 record could not be

found and 1 record was with HR pending an investigation.

From the 15 records tested, 8 records did not provide the date of the return to

work interview (3 of these are employees which have not returned to the

organisation and are still on long term sickness).

3+ triggers



Appendix A



We tested 5 records for 3+ triggers; 2 records in Brecon War Memorial Hospital (Epynt and Y Bannau Wards), 1 record in Llanidloes (Graham Davies Ward) and

2 in Bronllys (1 in Estates and 1 in Hotel Services).

Out of the 5 records, only 1 record had all the forms and documentation

completed (Brecon War Memorial Hospital). 1 record was with HR (Brecon War Memorial Hospital), 1 record had the point of contact form filled in but no back

to work information completed (Graham Davies, Llanidloes Hospital) and the 2

records at Bronllys Hospital had no point of contact forms filled in but had the back to work information completed.

There are two areas which raise concern: 1) Brecon – When the current Ward Sister was appointed 14 months ago most

staff were on 3 trigger points. The Ward Sister spoke on their behalf at sickness interviews and in agreement with HR it was decided that staff

would go back a trigger. The Ward Sister believes a great deal of the sickness was down to staffing issues and work pressures on the wards.

Sickness levels have improved significantly since the new Ward Sister has taken over; and

2) Estates – Historically a number of staff were on 3 trigger points and due to have formal sickness interviews. However, on initiating the interviews

there was no formal documentation to support the triggers detailed on ESR. It is understood that in the absence of any supporting documentation to

confirm that the sickness policy was being applied correctly all sickness

absence reverted back to zero.

The disparity between these two areas identifies inconsistency in approach across

the Health Board; Brecon staff were put back one trigger, whereas Estates Staff had their records effectively erased.



Appendix A




All sickness absence should be recorded and dealt with in accordance with the All Wales Sickness and Management toolkit.


Business Partners and HR Advisors will continue to work closely with managers

around sickness management. Monthly sickness focus meetings are held within Workforce and Operational Development where sickness is monitored and

specific cases reviewed in line with policy.

Director of Workforce and OD

May 2015

High



Appendix A



Finding 16 Impact

Annual Leave (Operation)

With the exception of Maternity Services, annual leave is not being entered onto

ESR and not approved prior to it being taken.

We understand that this is the case as the process is thought to be laborious on

ESR and leave on wards can be subject to change. In the absence of utilising ESR (though if this is the accepted method of approving leave this should be complied

with). If there are alternative systems operating, we would expect an alternative record which clearly identifies the leave entitlement, requests for leave and the

approval of leave before it is taken.

Poor and inconsistently completed records were found to be maintained on the wards with leave not being authorised prior to being taken.

Annual Leave not being recorded properly and too much being taken.


Leave should always be booked in advance and approved on ESR.

Where this is not possible, manual records should be maintained and kept up to date at all times. All leave should be authorised prior to being taken.

Medium



Appendix A




Leave should always be authorised before being taken whether this is by a

manual method or via ESR. ESR is the mechanism in which all annual taken should be recorded. ESR compliance reports are run monthly.

All staff will be reminded that all annual leave taken is to be recorded in ESR and

sent guidance on how to do this.


Development

May 2015

Powys Teaching Health Board Rostering – Effective Utilisation of


Appendix B

Audit Assurance Ratings

NHS Wales Audit & Assurance Services Appendix B

Audit Assurance Ratings

RATING INDICATOR DEFINITION

Su

bsta

nti

al

assu

ran

ce

- +

Green

The Board can take substantial

assurance that arrangements to secure governance, risk management and internal control, within those areas

under review, are suitably designed and applied effectively. Few matters require

attention and are compliance or advisory in nature with low impact on residual risk exposure.

Reason

ab

le

assu

ran

ce

- +

Yellow

The Board can take reasonable assurance that arrangements to secure governance, risk management and

internal control, within those areas under review, are suitably designed and

applied effectively. Some matters require management attention in control design or compliance with low to

moderate impact on residual risk exposure until resolved.

Lim

ited

assu

ran

ce

- +

Amber

The Board can take limited assurance

that arrangements to secure governance, risk management and

internal control, within those areas under review, are suitably designed and applied effectively. More significant

matters require management attention with moderate impact on residual

risk exposure until resolved.

No

assu

ran

ce

- +

Red

The Board has no assurance that arrangements to secure governance,

risk management and internal control, within those areas under review, are suitably designed and applied

effectively. Action is required to address the whole control framework in this area

with high impact on residual risk exposure until resolved.



Appendix C

Recommendation Priorities

NHS Wales Audit & Assurance Services Appendix C

Prioritisation of Recommendations

In order to assist management in using our reports, we categorise our recommendations according to their level of priority as follows.

Priority

Level

Explanation

Timeframe for

commencement of management action

Poor key control design OR

widespread non-compliance with key controls

PLUS

Significant risk to achievement of a system objective OR

evidence present of material loss, error or mis-statement

Immediate*

Minor weakness in control design OR limited non-compliance with established

controls

PLUS

Some risk to achievement of a system objective

Within One Month*

Potential to enhance system design to improve efficiency or effectiveness of controls

These are generally issues of good practice for management

consideration

Within Three Months*

* unless a more appropriate timescale is identified / agreed at the assignment.

High

Medium

Low



Appendix D


NHS Wales Audit & Assurance Services Appendix D

Confidentiality

This report is supplied on the understanding that it is for the sole use of the

persons to whom it is addressed and for the purposes set out herein. No persons other than those to whom it is addressed may rely on it for any

purposes whatsoever. Copies may be made available to the addressee's other advisers provided it is clearly understood by the recipients that we

accept no responsibility to them in respect thereof. The report must not be made available or copied in whole or in part to any other person without

our express written permission.

In the event that, pursuant to a request which the client has received under

the Freedom of Information Act 2000, it is required to disclose any information contained in this report, it will notify the Head of Internal Audit

promptly and consult with the Head of Internal Audit and Board Secretary prior to disclosing such report.

The Health Board shall apply any relevant exemptions which may exist under the Act. If, following consultation with the Head of Internal Audit

this report or any part thereof is disclosed, management shall ensure that

any disclaimer which NHS Wales Audit & Assurance Services has included or may subsequently wish to include in the information is reproduced in full

in any copies disclosed.

Audit

The audit was undertaken using a risk-based auditing methodology. An evaluation was undertaken in relation to priority areas established after

discussion and agreement with the Health Board. Following interviews with relevant personnel and a review of key documents, files and computer data,

an evaluation was made against applicable policies procedures and regulatory requirements and guidance as appropriate.

Internal control, no matter how well designed and operated, can provide only reasonable and not absolute assurance regarding the achievement of

an organisation’s objectives. The likelihood of achievement is affected by limitations inherent in all internal control systems. These include the

possibility of poor judgement in decision-making, human error, control

processes being deliberately circumvented by employees and others, management overriding controls and the occurrence of unforeseeable

circumstances.

Where a control objective has not been achieved, or where it is viewed that

improvements to the current internal control systems can be attained, recommendations have been made that if implemented, should ensure that

the control objectives are realised/ strengthened in future.

A basic aim is to provide proactive advice, identifying good practice and

any systems weaknesses for management consideration.



Appendix D


NHS Wales Audit & Assurance Services Appendix D

Responsibilities

Responsibilities of management and internal auditors:

It is management’s responsibility to develop and maintain sound systems of risk management, internal control and governance and for the

prevention and detection of irregularities and fraud. Internal audit work should not be seen as a substitute for management’s responsibilities for the

design and operation of these systems.

We plan our work so that we have a reasonable expectation of detecting

significant control weaknesses and, if detected, we may carry out additional work directed towards identification of fraud or other irregularities.

However, internal audit procedures alone, even when carried out with due professional care, cannot ensure fraud will be detected. The organisation’s

Local Counter Fraud Officer should provide support for these processes.



NHS Wales Audit & Assurance Services

Office details:

Audit and Assurance Hafren Ward

Bronllys Hospital Powys

LD3 0LS

Contact details

Kate Webb (Head of Internal Audit) – 01495 332052

Catherine Ketteringham (Principal Auditor) – 01874 712773 Rhian Spencer (Auditor) – 01495 332064

Documents

INTERNAL AUDIT REPORT Draft › sitesplus › documents › 1145 › WF&OD... · 2015-11-14 · Management Response: Responsible Officer: Timeframe: 2) Staffing Establishments The