1 Aim
The success of Rotherham, Doncaster and South Humber NHS Foundation Trust relies on all colleagues taking individual responsibility to provide and maintain a high-quality service and personal experience of care for all patients or service users. It is also fundamental that the trust, as a responsible employer, has a duty of care to support individual colleagues in carrying out those responsibilities.
Each colleague has a valuable role to play and a unique contribution to make that will ensure the highest possible standards of care are delivered and sustained.
The standard operating procedure for personal responsibility has been developed to encourage all colleagues to become involved in creating and developing an open culture with a focus on continuous improvement for all throughout the trust.
Personal responsibility is a philosophy or way of thinking that seeks to improve both the experience of those coming into contact with trust services and the experience of the workforce in providing or supporting care. It is a commitment to doing our best in providing safe, effective care for patients or service users and to continuously improve standards. Personal responsibility relies on:
- the trust providing a supportive approach to improving and changing behaviour and practice
- managers acknowledging where either they or the trust could have handled matters differently, or where systems and processes require revision
- each colleague realising they have an effect on situations they encounter and can contribute to improvements or changes at individual, team or an organisational level
- each colleague being committed to personal and organisational improvement
- creating a way in which colleagues can be positively involved and listened to, in contributing to quality and service improvement
- support the development and processes associated with clinical governance, patient safety, reporting untoward incidents, quality, service improvement, patient and public Involvement and risk management
- where incidents occur, the trust offering an opportunity for all involved to reflect on what happened and how any possible improvements can be made in the future
Encouraging the above should create a more open culture where all colleagues feel confident to highlight concerns without fearing punitive actions.
This approach is supported by the NHS improvement: A just culture guide, which confirms that fair treatment of staff supports a culture of fairness, openness and learning in the NHS by making staff feel confident to speak up when things go wrong, rather than fearing blame. Supporting colleagues to be open about mistakes allows valuable lessons to be learnt by all so that any errors can be prevented from being repeated.
2 Scope
This procedure applies to all colleagues, although in cases involving medical staff the principles of Maintaining High Professional Standards in the Modern NHS (Department of Health, 2003) must also be adhered to. Advice on disciplinary issues involving medical staff should be sought from the trust’s medical staffing department.
Seconded colleagues are covered by the policies of their employing organisation.
3 Link to overarching policies and procedure
This standard operating procedure is overarched by the disciplinary policy, but this procedure also links to the performance capability management policy and procedure and the civility, respect and resolution policy.
4 Procedure
4.1 Defining personal responsibility
Under this procedure the fundamental basis is that where any concerns arise, those involved reflect on their involvement, taking a shared responsibility for the matter giving rise to the concern and for any necessary improvements. This process is used to improve quality and to learn from mistakes, as managers and colleagues each reflect on their own responsibility for the things that happen around them.
When considering perceived concerns to be addressed under the personal responsibility framework, for those perceived concerns that are considered to be minor, they should be dealt with informally, encouraging reflection on personal responsibility and learning. In some cases, additional training, coaching and advice may be agreed to be appropriate. Any minor concerns should be discussed with those involved and an informal action note should be used to record the discussion and any agreed actions and support. This informal action note can be found in the disciplinary toolkit.
Where matters of moderate concern arise those involved are to be given the opportunity to reflect on the issue and how their actions may have contributed as part of a more structured personal responsibility framework meeting. The opportunity to address these concerns under the personal responsibility framework is often offered as an alternative to other formal processes such as the managing performance policy or the disciplinary policy. It allows individuals to reflect and accept their shared responsibility along with the trust and provide assurances for the future.
The personal responsibility framework is not designed to replace the disciplinary policy but may be used to deal with issues and concerns which are sufficiently serious, but not classified as potential gross misconduct issues, or where informal action has not proved to be successful.
For the avoidance of doubt the personal responsibility framework letters do not constitute a disciplinary warning and would not be detailed in any employment reference or impact on pay progression.
4.2 Determining the suitability for the personal responsibility framework
The procedure for raising an issue and identifying whether it could be addressed via a personal responsibility framework meeting is as follows:
- an appropriate manager, normally the line-manager will raise the concern with the colleague involved, or alternatively the colleague, when aware of the concern, should speak to their line manager about the issue or concern
- if the issue involves the colleague’s line manager, or they are not confident to speak to their line manager or supervisor, the colleague should discuss their concern with either the next level of manager, a human resources (HR) representative, a staff side representative or a member of the Freedom to Speak Up team
An initial fact-finding exercise should be undertaken by the appropriate manager to gather the immediate facts and determine whether any further action and or formal investigations are required.
The appropriate manager should consider the facts obtained and the severity of the concern. If the concern is of a minor nature, it should be addressed via an informal action note. The informal action note should be agreed with the colleague, and signed, if placed on their personal file. If the alleged matter is considered to be of moderate concern, they should contact the Human Resources team to explore whether the concern could be addressed via the personal responsibility framework.
A discussion should be held with the individuals involved to explain the outcome of the initial fact-finding exercise and the decision taken to offer the opportunity to address the alleged issue via the personal responsibility framework. The individuals should be informed that the alleged matter does not have to be followed through the personal responsibility route, however, declining the opportunity to do so may result in the alleged issue being pursued through the relevant policy or procedure (for example, performance management or disciplinary investigation). Managers should be mindful that in explaining an alternative process of investigation which may be taken, it is not inevitable that formal action will follow. Managers need to be sensitive and empathetic, when explaining the process, not to make refusal of PRF appear as a threat or a coercion of avoiding a more formal, serious procedure.
Prior to agreeing to move forward on a personal responsibility basis the individual should be advised that they contact their trade union or professional organisation representative for advice, should they wish to do so.
When determining whether the alleged matter could be addressed via the personal responsibility framework, consideration should be given to whether a colleague has already been through the personal responsibility framework due to similar concerns, but not completely dissimilar. Where this has been the case and an individual has provided assurances of future conduct during a personal responsibility framework meeting, however concerns of a similar nature have again been raised, the manager must discuss the alleged additional matter with a member of the Human Resources team to consider whether other policies need to be instigated to address this alleged new concern, such as the disciplinary policy.
Personal responsibility may also be a recommendation following a disciplinary investigation. In this instance the manager that commissioned the report would follow the principles stated above.
4.3 Holding a personal responsibility framework meeting
The individual will be sent a letter inviting them to a personal responsibility framework meeting. This letter will confirm that an appropriate manager and a human resources representative will be present and that the individual is entitled to be accompanied by a staff side representative or companion. This letter should be received at least 7 working days prior to the date of the meeting. A companion is defined as an official employed by a trade union or professional body or a workplace colleague. The letter will provide a clear outline of what alleged matters are at issue, with any supporting evidence.
The meeting will:
- provide the manager with an opportunity to discuss the alleged incident or concern with the individual involved in detail
- provide the individual with the opportunity to discuss the alleged issue from their perspective
- involve discussion of the alleged issue from an organisational perspective, it may be that the alleged concern is more a personal than an organisational issue
- explore the knock-on effects (where applicable) of the alleged incident or issue or practice
- identify the causes of the alleged act or omission to identify the responsibility of the individual and the wider responsibilities of management and the trust
- if the individual accepts a proportion of responsibility, discuss what actions or behaviours are more appropriate in the circumstances
- if the individual accepts a proportion of responsibility, provide the individual with the opportunity to give assurances as to their own future conduct
- if the individual accepts a proportion of responsibility, explore the range of remedial action available to assist the individual and or the trust, where the individual does not accept a level of responsibility that can be accepted by the manager or it is felt that the issue or concern needs further exploration, the meeting may be adjourned and consideration given to whether further investigation is required and or whether the alleged concern or issue should be managed through an alternative procedure and, or policy such as the trusts disciplinary policy or alternatively the manager may determine that no further action is required under this procedure or any other framework
- where a number of individuals are involved in the same alleged incident there is the flexibility to undertake a group personal responsibility meeting if all affected employees are in agreement and confidentiality can be maintained.
5 Remedial actions
If both the individual and manager accept that the issue raised has been addressed and that appropriate personal responsibility has been taken, there are a range of options available to assist individuals in achieving the required improvements identified. These improvements may be detailed within an action plan which the individual commits to as part of this process.
These may include:
- identifying specific training
- a clearly defined period of supervised practice
- increased frequency of clinical or management supervision for a determinate length of time
- access to assistance through staff support services, for example, referral to occupational health or counselling
- a mentoring arrangement
- a specific piece of research
- rotation to a different part of the service
- coaching in a particular area
- undertaking a review of a particular protocol
- reviewing the organisational policy or approach to a particular issue
- formal mediation
- management actions to address the situation, for example, develop specific training package or undertake communication or engagement sessions for wider team
- other locally agreed solutions
The manager will need to consider how best the appropriate support and improvement may be achieved, in relation to both the colleagues and the trust. It might be that more than one remedial action is offered to the colleague and or instigated by the trust. The success of the standard operating procedure will depend on managers extending latitude to individuals where that is appropriate. Additionally, assisting other managers across the trust to accommodate specific training needs or to provide mentoring services for their colleagues.
Set methods of measurement should be agreed regarding any necessary improvement. Where a colleague fails to demonstrate an improvement, despite support and remedial action, use of the disciplinary or formal capability procedures may be necessary in accordance with the relevant trusts policies.
5.1 Personal responsibility framework letters
Whilst colleagues will generally be informed of the outcome of the personal responsibility framework meeting at the conclusion of the meeting, it must also be confirmed in writing, usually within seven calendar days of the meeting. Consideration must be given to information governance requirements available within the information governance policy and management framework, information governance employee code of conduct and information governance handbook.
The letter should have details of the agreements reached, the circumstances or behaviour that led to its issue and the consequences of failure to change such behaviours.
If the colleague or colleagues disagree with the content of the outcome letter, including lack of proof to support the alleged issues discussed, then this should be addressed by informal request for the letter to be amended, or a further meeting. Should disagreement arise, then the colleague can use the grievance policy to address their concerns.
It is the responsibility of the manager conducting the meeting to ensure that this letter is sent to the colleague and their representative as well as a copy included in the colleague personal file.
The personal responsibility framework (PRF) will remain active for 6 months from the date of the meeting (although if the colleague is absent from work for a period of over four weeks during this period, the personal responsibility framework will be extended to reflect the period of absence) and will be disregarded after this time. However, a record of the first written warning will remain on the colleague’s personal file for 6 years.
5.2 Reasonable adjustments
In applying this procedure, managers and the human resources department will ensure that reasonable adjustments are made for colleagues with disabilities or literacy difficulties, religious beliefs or culture or for whom English is not a first language. Where a colleague who is facing a personal responsibility framework meeting feels that such adjustments are necessary, they should initially discuss the issue with their line manager.
Document control
- Version: 3.
- Unique reference number: 465.
- Approved by: people and teams group.
- Date approved: 9 December 2025.
- Name of originator or author: human resources advisor.
- Name of responsible individual: human resources partner.
- Date issued: 22 December 2025.
- Review date: 31 December 2028.
Page last reviewed: December 22, 2025
Next review due: December 22, 2026
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