Personal responsibility framework SOP

1. Aim
2. Scope
3. Link to overarching policy and or procedure
4. Procedure or implementation
5. Remedial actions

1 Aim

The success of Rotherham, Doncaster and South Humber NHS Foundation Trust relies on all employees taking individual responsibility in order 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 employees in carrying out those responsibilities.

Each employee 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 employees 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 employee realising they have an effect on situations they encounter and are able to contribute to improvements or changes at individual, team or an organisational level
• each employee being committed to personal and organisational improvement
• creating a way in which employees 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 employees 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 staff to be open about mistakes allows valuable lessons to be learnt by both employer and employee(s) so the any errors can be prevented from being repeated.

2 Scope

This procedure applies to all trust employees, 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 employees are covered by the policies of their employing organisation.

3 Link to overarching policy and or procedure

This standard operating procedure is overarched by the disciplinary policy, but this SOP also links to the performance capability management policy and procedure and the respect, civility and resolution (formerly bullying and harassment) policy.

4 Procedure or implementation

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 employees 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 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.

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 employee involved, or alternatively the employee, when aware of the concern, should speak to their line manager about the issue or concern
• if the issue involves the employee’s line manager, or they are not confident to speak to their line manager or supervisor, the employee 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 employee, and signed, if placed on their personal file. If the alleged matter is considered to be of moderate concern, they should contact the Employee Relations team to explore whether the concern could be addressed via the personal responsibility framework.

A discussion should be held with the individual(s) 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 individual(s) 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 may make contact with 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 an employee 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 Employee Relations 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 HR 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 in order 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 SOP 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