Scottish Government

4 DEVELOPMENT OF PILOT PROCESSES

Introduction

4.1 This chapter outlines how key pilot processes and underpinning structures were put in place by NHSQIS and the pilot sites including: the preparation of Workplace Supervisors; the learning and assessment materials and process; the fit with KSF and local induction and training initiatives; the Disclosure Scotland application process; arrangements for the occupational list. We present the views of workplace supervisors on training and support received plus the perspectives of key stakeholders on development of all process. Further detailed description of processes can be found in Annexe I.

WPS training and support

4.2 The evaluation aimed to assess the initial training required for workplace supervisors ( WPS) and how onerous the process of supervising HCSWs through the process was for them.

4.3 The centrality of the Workplace Supervisor role became more apparent as the pilot progressed. Sites felt pre-pilot planning had failed to fully address issues relating to the WPS role, particularly resource implications and what might motivate them to be involved. The role is set out in the Guidance ⁴² but implications not fully addressed included: was participation 'voluntary' for WPS, what were the motivators; would the WPS role fit with their existing role, how much of their time was required and what was required to support them though the pilot?

4.4 The identification and engagement of workplace supervisors proved far more difficult for the first two sites than anticipated and flexibility in training approach and delivery proved essential. Stakeholders and WPS felt supervising HCSWs through the process was not particularly onerous, but there were sometimes great difficulties in WPS and HCSW successfully linking up to start and complete assessment.

4.5 Pilot stakeholders reported that in practice, there were many potential barriers to identifying and securing WPS engagement with the pilot. For a WPS to take an active part in the pilot they had to be both released to take part and motivated to be involved. Managers were not always willing to release WPS from busy wards for an unspecified amount of time for training and to undertake assessment of HCSWs. The timing of HCSW consent, WPS identification and training varied in practice across sites and over time and this would appear to be related both to the size of the pool of eligible HCSWs and to the local pilot style. Focused recruitment of HCSWs at Lanarkshire ( Chapter 6) aided engagement of WPS and their release by managers and a large group training approach worked. The other two sites found there was no simple system in place for identification of WPS and training had to be very flexible, and resource intensive, to accommodate diverse WPS work patterns.

4.6 The Guidance intended that an individual's KSF reviewer would also be the pilot WPS; but during the time of the pilot, KSF was not yet fully implemented (section 4.57). Although the WPS role could be seen as integral to a supervisor's normal role, including induction and monitoring staff, some already very busy staff (or their managers) were not keen that they take on what was an additional and, in some cases, very substantial extra task.

Table 4.1 Number of Workplace Supervisors

4.7 By the end of September 2008 a total 227 WPS were trained (Table 4.1) an approximate ratio of 1 WPS: 2 HCSW for the final 470 HCSW volunteers, (or approximately 1 WPS: 1 HCSW for those HCSWs attending an initial meeting with their supervisor).

4.8 At the outset pilot management and the pilot sites agreed that the SQA⁴³ model of approximately 1 WPS to 3 HCSWs would be about right. In places, with some clinical staff groups this looked like it might be possible. However for non-clinical groups this was much more problematic. At one site the low ratio of supervisors to domestic support staff proved to be a serious obstacle (5 managers for 99 domestic staff). Only 3 managers were available to assess the 21 recruited domestics. It was agreed to tackle this on a phased basis but this would mean that it would take a long time to progress all the domestic recruits. Other non-clinical groups (catering, portering and laboratory services) also faced this same low WPS: high HCSW ratio issue.

4.9 Once the WPS had been enabled to undertake the task their level of enthusiasm was very important to securing recruitment of HCSWs. Local Pilot Coordinators reported that a really motivated charge nurse could bring in a whole ward of HCSWs and ensure the process was followed through ( e.g. one Lothian hospital sent 17 WPS for 34 HCSWs over 3 training sessions).

4.10 There was a wide range of WPS experience of regulation culture and experience of formal assessment, using and recording of evidence. As anticipated at the outset, clinical supervisors/assessors were more familiar with the mentoring/supervisory role than some support services supervisors. Within some ancillary staff groups (catering, domestic service, portering) the supervisors themselves are not regulated and stakeholders felt they may be less likely to see the potential benefits for their HCSWs. For some it was entirely new and for others there was considerable overlap with work already done ( e.g.SVQ or Domestic Workbook assessment). Some support services staff took longer to get to grips with the handbooks and the concepts of assessment and evidence.

4.11 It was initially envisaged that a half-day training session would be sufficient to inform the WPS role. In practice there was considerable variation in content and delivery across sites, over time and across groups of staff. The training package appeared to develop over the life of the pilot, and simpler training materials were found to make the pilot more accessible for support staff. Within all sites, there was a view that it was not efficient to train too many managers in advance of HCSWs being recruited as there would be too long a gap before they could start assessment work.

4.12 From evaluation observation of training sessions the WPS attendees appeared generally in favour of the pilot but raised a number of questions. These, for example, related to what to write for assessment evidence, queries about paperwork, fears about potential HCSW fees, how HCSW circumstances might change (pay, conditions, further training opportunities), what the ratio of WPS to HCSW would be, what was the SWISS database. One group of WPS supported HCSW development but were sceptical because they found that in practice their own training requirements, as identified in Personal Development Planning, were not actioned.

4.13 There was clear pilot stakeholder feeling that further work needed to be done to assist supervisors who did not normally do that kind of assessment ( e.g. some support services staff) to develop the required skills. Lead officers from at least one participating pilot Health Board were clear that their Workplace Supervisors should have at least a basic level of assessment experience and preferably a relevant SVQ before undertaking the WPS role. From evaluation observation, the WPS training pack included handouts as memory aides on assessment skills, but this element was only very briefly touched on during training.

4.14 The evaluation case studies, questionnaires and the NHSQIS review of completed assessment materials all indicated that more needed to be done to ensure that Workplace Supervisors were clear about what might constitute evidence for a standard and what needed to be recorded.

4.15 The evaluation's WPS survey results below indicate that the majority of WPS were willing volunteers. They were motivated by aiding HCSWs and patients and by career development. They were very supportive of the pilot aims but felt the induction standards were best aimed at new starts. However they had concerns about the time commitment required of them, fitting the task into already busy jobs was an issue and only half felt sufficiently supported with this. Half felt 1 to 2 HCSWs to supervise was the right level and this suggested that the envisaged 1 WPS to 3 HCSW ratio was overly optimistic.

4.16 The evaluation found that in future the WPS role would require much further development and considerably more resource to cover WPS training and assessment time. The use of 'own time' for preparation found in pilot needs to be acknowledged. The support of middle managers is essential and consideration needs to be given to how best to meet the needs of low WPS: high HCSW ratio groups. Stakeholder suggestions include using peripatetic assessors or additional supervisors or a 'mentor' similar to those in place for student nurses. A 'mentor' would take overall responsibility for the HCSW but not necessarily assess every element (this might assist in situations where ward qualified nursing staff did not take responsibility for bank staff).

4.17 Areas to be further explored include:

• flexible approaches to meet diverse work groups and work patterns
• motivators for WPS across a more diverse range of staff groups
• preparatory work on the principles of regulation, evidence and assessment for workgroups where this is not already part of the culture
• Disclosure Scotland clearance for potential supervisors without this already
• review of WPS training materials to develop a consistent and comprehensive package; materials need to be fully accessible and delivery needs to meet needs of all work patterns
• the potential for e- KSF to make explicit the WPS/ HCSW link

The views of Workplace Supervisors

Table 4.2 Workplace Supervisor survey response

4.18 Workplace Supervisors' ( WPS) views were gathered by the evaluation team via the WPS survey and the case studies. The WPS survey had a 38% ( 92) response rate ⁴⁴. Ayrshire and Arran (42%) and Lanarkshire (49%) had similar response rates, but the relatively smaller response from Lothian (19%) suggests possibly less engagement from WPS at this site (Table 4.2). The returns were biased towards those working in older people's services and these came mostly from Lanarkshire (Table 0.10). There were responses from both hospital and community settings, including those working in patients' homes. Over half the responses were from nursing (57%, 51) and allied health (38%, 34) plus 4 domestic and 1 laboratory staff (Table 0.8). Most supervisors were on bands 5-7 and already carried out a formal assessment role (79%, 68).

4.19 Most supervisors first heard of the pilot from their line manager (84%, 77) and this was true for 90% ( 43) from Lanarkshire (Table 0.16).

4.20 Two-thirds (67%, 60) felt that it was their own decision or a shared decision with their line manager to take part in the pilot and the remaining third (33%, 30) thought it was a decision made more by their line manager or a senior manager. A larger proportion felt it was their own decision in Ayrshire & Arran (79%, 23) than Lanarkshire (62%, 29). Overall most supervisors (63%, 56) were clear they wanted to take part.

4.21 A quarter (26%, 24) had no concerns before starting the pilot (Table 0.17). The main concerns were that there 'might be too much work' (48%), too busy at work' (47%) or 'might get too many HCSWs to supervise at one time' (16%) or personal commitments (9%) (Table 0.18).

4.22 The main motivator for taking part in the pilot was 'to help the HCSWs in my ward/unit' (71%) followed by 'to improve patient safety and public protection' (50%); 'learning new things' or 'a development /career opportunity' were equally important (29%) and 'having my say' a reason for fewer people (16%) (Table 0.19).

4.23 The survey confirmed the variety of training formats delivered. In Ayrshire & Arran more had attended a small group session of 3-6 participants (60%) and 5 had had an individual or paired session. In Lanarkshire more (58%) attended a larger group session of 7 or more participants. Training sessions were generally a half day but some Lothian ( 10) and some Ayrshire supervisors ( 14) noted shorter 2 hour sessions (including at least 2 night shift and 3 weekend workers).

4.24 Most supervisors (89%, 81) found the training about the right length and that it gave them all the information they needed (63%, 57). However half (52%, 48) felt they needed to do further preparation after training, and more felt this at Ayrshire and Arran (69%, 20). One in five supervisors undertook further background reading. Preparation included: discussing with a colleague/other WPS (33%, 30); thinking of oral and observation assessment examples (32%, 29). Of those doing further preparation, just 7 supervisors had done all the preparation in their own time, half (53%, 35) did some in their own time and the remainder (37%, 25) did it all in work time. Quite a variety of 'own time' was cited, from a couple of hours to three days. The most common was commonly cited was 1-2 or 3-4 hours, but also 5 hours or one day, several evenings or sessions over the six month period. Just nine supervisors noted that they felt using their own time was 'unreasonable'.

4.25 Around half (46%, 42) of the supervisors contacted the LPC for further clarification after initial training. This indicates the need to build in additional supervisor preparation time after the basic training and confirms the need for LPC support. A fifth wanted a three way meeting with their LPC and HCSW to clarify issues to do with evidence of prior achievement (22%, 20) and assessment (29%, 27). In 10 cases LPCs had arranged a three way meeting to clarify assessment issues and in 6 cases this had involved a difference of opinion between the WPS and HCSW. No WPS had found it necessary to contact a Union representative to clarify anything.

4.26 Over half of the supervisors (58%) were supervising just one HCSW and a further 37% were supervising 2-3 HCSWs. In their current post, most WPS (82%) felt they could supervise 1 (39%) or 2 (43%) HCSWs through the standards at one time. Just 16% felt they could supervise 3 at one time.

4.27 Although most WPS felt supported by their department, line manager and LPC (73-79%) a smaller number felt the Board provided all required support (39%, 36). Only half 50% ( 46) felt supported to take the time required in their role as WPS and 20% ( 18) definitely did not feel supported to take the time required (this included representatives from bank, weekend and night shift staff).

4.28 Two thirds (57%, 51) did not find it easy to fit the WPS role with their other work and there was some indication that nursing assistants (73%, 37) found it harder to fit and that allied health support staff found it "very" or "fairly easy" (66%, 21). Some (10) wrote comments on the great difficulty in getting the time to complete assessment and paperwork or being able to meet their HCSW (6).

The most difficult part of the pilot was finding the time to carry out the assessments due to differing shifts, sick leave and annual leave. It was difficult to set aside time due to restraints within the ward and ever changing clients.

(Staff Nurse band 5, acute hospital, mental health services, working 12 hour shifts, weekend and nights)

4.29 Three-quarters (77%, 69) found the Workplace Supervisor Handbook easy to use or about right but one in five (21%, 19) found it hard to use and felt the paperwork could be amended. The main issues with the materials overall were that there was: too much paperwork, too long, too much duplication, too 'wordy', poor correlation between HCSW and WPS handbook, poor signposting to sections and duplication across elements.

• The handbook is enormous and therefore quite daunting
• Far too long and repetitive, difficulty particularly with oral questions
• I felt there was a lot of writing to be done
• Needs to be simpler

4.30 On the whole supervisors felt the assessment documents would be better for new staff at induction and most (20) written comments related to the HCSWs already working at or above these standards.

Our work is predominantly in schools. Many of the questions appeared to be more relevant to ward settings. Our Healthcare Support Workers have NNEB qualifications and some have degrees. I found the questions too easy and we found ourselves looking at the questions in too much depth.

(Speech and language therapist, band 7, working 9-5 with children in schools)

4.31 The survey responses indicated that WPS supported what the pilot was trying to do. Around 84% thought the standards should be in place both for their own HCSWs and for HCSWs in different jobs. Most (92%) thought the standards should be in place across all Health Boards and slightly fewer (83%) also thought the list should be in place (Table 0.21).

Domestics like doing the course. They forgot how much they do day by day, about the standards and how high standards are achieved, how much nurse and domestic work together for all clients needs.

(Hotel services supervisor, mental health services, community based working 8 hour shifts)

The assessment process and materials

4.32 The evaluation aimed to identify the processes used to assess achievement of the standards and entry to the list. The pilot developed an assessment toolkit to aid the HCSW in working towards and evidencing achievement of the basic induction standards. A checklist was developed to ensure all required evidence and Disclosure Scotland outcome was in place before the successful HCSW was entered upon the list (section 4.91).

Format of final process and materials

4.33 The assessment toolkit developed for the pilot consisted of two handbooks, a Healthcare Support Worker handbook and a parallel Workplace Supervisor Handbook. The two handbooks varied slightly in content ( Annexe I). The final HCSW assessment tool had two parts: an observation assessment and an oral assessment. The process was intended to take the following steps. Firstly an initial meeting between HCSW and WPS would be held. This would map out an approach towards achieving the standards and identify any development/learning needs. Evidence of previous achievement would be considered if appropriate. A date for the Observation and Oral assessment elements would be arranged. On completion of the assessment the HCSW would sign the Code of Conduct Declaration and commit to working to the Code at all times in future. Once the Disclosure Scotland outcome was known the HCSW could be entered upon the occupational list and could receive a Certificate of Completion.

4.34 The Guidance suggested that the HCSW should achieve the standards within three months and the Handbooks said as many reassessments as required could be undertaken up to six months. If the HCSW still failed to meet the standards, a three way meeting between HCSW and WPS and LPC would be convened to identify any obstacles and/or further learning opportunities. If the standards were still not met then, as stated in the Guidance for Employers and outside the pilot arrangements, the NHS Board would follow existing capability procedures.

Experience of the development process

4.35 The pilot management team faced many challenges in developing the assessment materials and process. Assessment was intended to ensure that the HCSW understood the purpose of the public protection standards and had achieved this basic induction level. The formative stage of the evaluation found that there was no shared view as to how the new standards might be operationalised or measured. It was not known what induction processes already in place at each NHS Board might provide evidence of prior achievement. Site lead officers were however quite confident that much induction material would very likely be useful and that many HCSWs already held SVQs.

4.36 The timescale for development was very tight; this was exacerbated by the absence of the first NPC. In addition to the lack of pre-pilot development there were early mixed stakeholder views about the way to approach devising an assessment approach. Using the Home Care Practice Licence Tool ( HCPL) ⁴⁵ as a starter model both aided and hampered the process. Despite these difficulties, the process moved forward quickly on appointment of the second NPC and was aided by the commitment and contribution of skills from the LPCs and lead officers at the first two pilot sites. The pilot team managed to develop a comprehensive set of working materials, test them with a wide range of staff ( Chapter 7) and facilitate a quality assurance exercise ( Chapter 9).

4.37 Partnership representation to the 4 Country Steering Group (April 2007) underlined the need for a nationally agreed assessment tool to be consistently applied across sites and worker groups. The NHSQIS Project Steering Group confirmed that the assessment process and guidance must be in place prior to recruitment of HCSWs. Members of the assessment working group then felt that there was considerable pressure from SGHD to have the tool developed by the end of May 2007, in order to facilitate a full operational year once HCSWs had been recruited. The finalised first drafts of materials were tabled at the July 2007 meeting, more than six months into the project, and subsequently approved by local steering groups. The handbooks were finally approved and disseminated to pilot sites in August 2007.

4.38 The Guidance was clear that NHSQIS had a role in quality assuring processes at participating NHS Boards but was not specific about the development of such processes. Initially there was some expression of tension between the first two participating Boards' desire to approach development of the assessment tool on a local basis and the intended NHSQIS centrally-led approach. SGHD and NHSQIS had already commissioned initial work from Stirling University to undertake a preliminary mapping of the HCPL against the pilot's assessment requirements.

4.39 The Home care Practice Licence Tool developed by the Dementia Services Development Centre ( DSDC) of Stirling University, is a tool for validating the knowledge, skills and competence of home care workers. The pilot management considered the model to be of potential value for three key reasons. It had already been fully piloted in 2003-2005 across seven different organisations ⁴⁶. The HCPL was based upon the Driving Standards Agency model of the UK driving test, consisting of three components: a theory test, a practice observation and oral questions. It was aimed at a comparable worker group, home care workers without a recognised qualification in care, and it was relevant for both staff who had completed induction and preliminary training and experienced workers. The test could determine the effectiveness of induction training, skills gaps and training needs, and in addition to validating competence, would encourage workers towards further development. It had also been proved suitable across a variety of work patterns, validating the practice of those not able to participate in higher level qualifications for a variety of reasons ( e.g. working short part-time hours, approaching retirement).

4.40 A working group ⁴⁷ was set up ( LPCs and some site lead officers, NPC, NHSQIS, the KSF national lead and the HCPL team) to progress development. The initial mapping indicated some key issues. The HCPL model differed in cultural tone and style from the standards and applied to a single rather than diverse group of workers. Importantly it focused more on service user outcomes rather than organisational and employee responsibilities. There were also questions about using all three elements of the HCPL model. Whilst there was support for the practice observation and oral assessment elements, there were very varied views about the applicability of using a written test.

4.41 Members of the working group felt the work was hampered by several factors. The absence of the first NPC hampered early communication and planning with DSDC and slowed progress. The group had to await appointment of the LPCs and their contribution of a more detailed health perspective. The new NPC, with authority to steer decisions then quickly moved the process along. Energy was spent in attempting to adapt the HCPL multiple choice test element with its associated handbook ( i.e. generating test questions and example right and wrong answers for HCSWs). Time was also lost in the exercise of mapping the existing HCPL questions to the HCSW induction standards for the observation and oral assessment elements ( i.e. adapting the HCPL tool rather than focussing upon what was required to measure the HCSW induction standards as already published). Early drafts of materials failed to capture all the information required in the standards.

4.42 There were differing views about the appropriateness of a written test for HCSWs, given the wide range of literacy levels across groups ( Annexe J). The SGHD view that it had always been clear that a written test was not to be included was not apparent to the assessment working group and this was confirmed at the May NHSQIS National Project Group. However there were some remaining differences of opinion about the removal of the written test element from the assessment. There was a general understanding that a written 'test' might have been off putting for some HCSWs with relatively low literacy skills. The NHSQIS Project Group decision was that a test, with a pass/fail mark, was inappropriate for the very wide range of HCSWs and out of step with the more usual NHS model focusing upon workplace learning and development. However others felt that HCSWs would have easily been able to undertake the simple test of straightforward common sense questions just as thousands are able to undertake the theory element of the driving test. One view was that, had an objective electronic test been used, there might have been opportunity to obtain easily comparable measures across Health Boards, but such a system would carry resource implications.

4.43 The working group found that varied possible interpretations of the standards caused difficulties when creating assessment materials. It was not always clear what standards meant, why there was repetition across standards and performance criteria and what might be expected or appropriate in terms of evidence. As the purpose of the pilot was to test the standards as published; there was no scope for reformatting or rewording the standards, which had already been consulted upon.

4.44 The working group developed oral and assessment materials to fit the HCSW standards and criteria. It became clear that certain observation criteria would be difficult to evidence in practice and these would be better covered by the oral assessment (Standard (S)5: reporting incidents at work; (S)6: working within confidentiality guidelines; (S)14 whistle blowing in cases of harm and abuse). The oral assessment paper was generated from a database of 105 questions designed to cover all the standards performance assessment criteria. The working group confirmed that all 25 observation criteria and 30 oral questions were to be satisfactorily met to indicate the HCSW had a minimum threshold of knowledge and could carry out a particular role safely.

4.45 Finally, the National Management Group considered the Code of Conduct and decided that assessment of the HCSW's understanding of the Code was not appropriate; any testing would necessarily be subjective as the Code provides guidance on appropriate behaviour. A mapping of the code to the induction standards indicated that if the latter were achieved then the HCSW would be working to standard and the Code of Conduct. Therefore a Code of Conduct Declaration form was developed for the HCSW to sign on completion of the observation and oral assessment, and to agree to work to at all time throughout their working career.

4.46 NHS Education for Scotland ( NES) reviewed the final handbook drafts for their appropriateness for learning. A small number of minor amendments were subsequently made to improve print layout and accessibility, to use Plain English; to make a few oral questions more explicit and the wording of observation criteria more consistent. NES suggestions towards a more elaborate professional print job were not followed at this stage due to pilot budget constraints but might be appropriate if further roll-out is pursued.

4.47 A complaints and appeals procedure (available in the HCSW handbook and separate from any already in place at pilot sites) was designed by NHSQIS to ensure all HCSWs being assessed during the pilot had opportunity to raise any concerns connected with the process and appeal any assessment decision. As no complaints have been made this has not been tested during the pilot.

Stakeholder views of the final materials

4.48 At the end of the pilot there was general consensus that a single approach across sites provided greater consistency within an employer-led model, but there was some expression that having used a single approach did not allow the testing of whether this was the right assessment approach or whether other approaches might have worked better.

4.49 Pilot site stakeholders felt that HCSWs were generally positive about the process and that it had been well received by participating HCSWs, that it had given them opportunity to consider their own development and had boosted their confidence.

4.50 All those involved in developing the tool kit were largely happy with the end result given the short amount of time to develop it. However, by the end of the pilot it was clear that there was still a lot of work to be done. The two handbook format had been based upon the HCPL guidance model. After testing it in practice it was apparent that stakeholders felt there was much duplication across the handbooks and across guidance and assessment papers within the handbooks. The ring binder formats were helpful, offering HCSWs a chance to take ownership and add their own supporting materials and evidence. However it all needed to be streamlined and repackaged, probably to one single simpler set of materials so that it appeared less cumbersome and off-putting to both HCSWs and WPS. There were many reports from stakeholders and the evaluation surveys and case studies about difficulties of repetition, 'wordiness' and difficult and not easily understood language.

4.51 The working group explored drafting lists of key points or sample answers as examples for the oral questions. There was lack of time to develop appropriate examples across a wide spectrum of disciplines and services and respondents were concerned about the potential for examples to be misinterpreted as 'correct answers'. Therefore it was decided this would be better considered in future development.

Fit with other induction and training processes

4.52 The assessment development working group and pilot stakeholders had much discussion about how the WPS would assess the accreditation of previous qualification as evidence for the standards, its relevance to the current role and currency of application. No formal mapping of the standards to induction, SVQs or induction was in place at the start of the pilot. Therefore the WPS, in assessing the achievement of standards would be making individual judgements about which elements of previous qualifications might provide evidence for any individual HCSW role.

4.53 As anticipated there were multiple induction processes in place at each Board and various combinations of core and more localised induction by area of work. The evaluation found that although some preliminary work had been conducted at sites towards mapping local induction processes against the standards this had yet to be completed. For example, Lothian was originally a national pilot area for an induction programme with online induction modules completed for all staff and initial mapping against the standards indicated some fit but also quite a lot of gaps. The role of induction was examined more formally during the Board self-assessment exercise.

4.54 The 4 Country Steering Group had agreed at an earlier stage that any qualification credit negotiations would come following completion of the pilot (the performance criteria included against each standard statement would enable an SCQF rating to be considered at a later date). Lothian initially used the potential for the standards to contribute to SVQ accreditation as a major selling point to its staff. They had preliminary discussion with Care Scotland and SQA about the potential for the HCSW assessment process to provide credits for VQs but the assessment papers had not been put forward for any formal process of consideration. No formal mapping was undertaken by other sites.

Fit with Knowledge and Skills Framework and Personal Development Planning and Review ( PDPR)

4.55 A key aim of the evaluation was to explore whether the process used to demonstrate and document HCSW achievement of the induction standards had potential to be linked to the Knowledge and Skills Framework ( KSF) ⁴⁸ foundation gateway of Agenda for Change. We also aimed to explore whether there would be any additional burdens entailed by the standards on top of the KSF requirements and whether KSF outlines for HCSW roles could accommodate the national standards being tested.

4.56 The Guidance sets out the intended relationship between the standards and the KSF procedures. The standards are achieved through induction and can be used to support ongoing development within KSF; processes used for collection of evidence should be the same as that used for KSF review; evidence should be gained and documented through the personal development planning and review process ( PDPR) ⁴⁹; different systems for carrying out PDPR are in place, including KSF. The Code of Practice notes that trained supervisors should provide formal assessments as well as plan for personal development to meet KSF, and employers should consider using e- KSF⁵⁰.

4.57 The evaluation found that the potential burden of the induction standards over and above KSF requirements had not been tested during the pilot. The Guidance pre-supposed that KSF would have been implemented ⁵¹ in participating sites and that a KSF outline and PDPR process would be in place for each HCSW. Pilot site stakeholders indicated that KSF roll-out was still at an early stage and was implemented to different degrees across sites, services and groups of workers. Roll-out appeared further ahead at Ayrshire and Arran (but with mainly paper based KSF) than in Lothian; Lanarkshire was reported to be further ahead in training reviewers ⁵².

4.58 NHSQIS and the KSF lead encouraged pilot sites to try to identify a sample of WPS/ HCSW who could illustrate how the two processes might fit together. Stakeholders reported that the local KSF officers' clear priority was on implementation of KSF rather than on the requirement to consider fit with the pilot standards. Pilot sites found it was not easy to identify HCSWs who were doing both processes. Two sites did identify a sample of HCSW volunteers who were new in post or who had recently had a KSF outline assigned, with the aim of exploring whether evidence collection could inform both processes. LPCs also hoped for feedback from other HCSWs, who were further along the KSF process, on if and how evidence collection for induction standards had informed the KSF development review. Neither set of feedback was available to the evaluation team by the end of the pilot. There was some limited anecdotal evidence from WPS feedback forms to suggest that the standards might complement the KSF process.

4.59 Local Pilot Coordinators were concerned about the potential burden of organisational effort in running the two processes together, and that WPS might be put off by the potential burden of doing both processes at once. It was felt that already drafted training materials might need to be adjusted to include more specific reference as to how HCSW standards might provide KSF evidence.

4.60 Pilot stakeholders found that there were potential difficulties in the ' KSF outlines' accommodating the induction standards as there were some differences in scope. The original KSF lead officer was involved in the review of the standards, post consultation and pre their final publication. Further work did not take place until August 2007 when the KSF lead, NPC and LPCs and a UNISON representative met. They undertook a paper based exercise to map the two together (a detailed report of which will be available in the NHSQIS project report ⁵³).

4.61 KSF deals with development and application of skills and knowledge within the post. There were concerns as to whether the fourteen public protection statements were accurately cross-referenced to KSF dimensions ( Annexe K) and there was some concern about ambiguity in interpretation and duplication across the standards. The induction standards and Employee Code of Conduct also address capability and performance areas - these would need to be dealt with outside the KSF process. Such aspects would definitely not be recorded on e- KSF currently and would therefore need to be recorded separately. These behavioural aspects concern not what an HCSW knows but how they are expected to undertake the task ( e.g. safely, maintaining patient dignity, with the correct attitudes and behaviours).

4.62 A task for the pilot was to explore how the WPS could differentiate these elements and be clear about what would be recorded for induction and what for KSF in practice. As we have seen it was not possible to test this with any HCSW and WPS undertaking the assessment process for the pilot.

4.63 There were also some issues to do with terminology. KSF refers to 'reviewers' rather than 'workplace supervisors'. Some stakeholders felt that the term 'induction' itself could be problematic to some extent as it is used in many different ways (it could encompass a self-contained two day workshop or continuous assessment over a period of time).

4.64 The relative timing of the two processes was also an issue. The first KSF gateway is to be met at twelve months and if the induction standards are to be met at 3-6 months then signing off of this process will need to stand independently. At the consultative workshop questions surfaced about whether the length of time for achievement of the standards should apply to full completion of all the standards only or whether a more differentiated approach was required ( e.g. particular standards should be achieved within days or weeks rather than months).

4.65 By the end of the pilot NHSQIS anticipated that evidence from achievement of the induction standards would help to inform the interim and final foundation KSF reviews and that the completed documentation could be loaded onto e- KSF when it is rolled out across Scotland ⁵⁴. The requirements of both the induction standards and KSF were felt to be open to interpretation. Some of the induction standards performance assessment criteria did not easily map across to KSF. Some standards requirements would not be included in all HCSWKSF outlines. Rather than progressing further work on clarifying links between standards and KSF outlines it was felt a more useful way forward would be to use the same skills assessment and evidence collection process to inform both processes. Once the induction standards had been achieved and the evidence had informed a successful foundation gateway review, maintenance of the standards could be evidenced via further KSF reviews.

4.66 The potential relationship between the Employee Code of Conduct and the KSF review was still not entirely clear. NHSQIS were suggesting that working to the Code of Conduct should inform the HCSW's KSF personal development plan. However, as we have seen, the Code includes behavioural aspects which cannot easily be monitored under KSF. For example, should an HCSW breach the standard 'Confidentiality' by inappropriately giving out information about patients or treatment this might be a conduct error but not necessarily an illegal act. Such an act would need to be considered under staff governance procedures and may or may not result in dismissal. (The employer may choose to take into account factors such as training received by HCSW, scope of the breach, intentionality, harm caused etc).

4.67 During the pilot NHS Boards were working upon developing Gateway/Review policies to outline when issues coming up at a review no longer fell under KSF but needed to move into a management process. Organisations faced a learning curve, there was no national level document but it was anticipated that good practice would be shared via the KSF Leads Network and the Human Resource Directors Group. It is also not clear at present how such practice will be affected by forthcoming arrangements under vetting and barring procedures under the Protection of Vulnerable Groups (Scotland) Act.

4.68 In summary it appeared that the way the induction standards and KSF might work together had not as yet been fully explored. Stakeholders felt there needed to be further exploration of KSF core standards to see if anything in addition to this was required for clinical groups

4.69 It was clear that any future adjustment to KSF would need to be undertaken under 4 country KSF and partnership agreement. E- KSF has the facility to upload files of supporting evidence (word documents, scanned certificates); it would be hoped to avoid duplication and any material outside the KSF remit would need to be excluded.

The Disclosure Scotland Application process

4.70 The evaluation aimed to assess SCRO capacity to meet pilot demand for 'enhanced' DS criminal record checks and also whether systems were in place to record and deal with previously unknown convictions uncovered through DS checks.

4.71 The SGHD Guidance to participating Boards indicated that, before an HCSW could be entered upon the occupational list, the employer must evidence that the HCSW had been safely recruited against the standards set out in the Code of Practice for Employers ⁵⁵ including the PIN guidelines. The PIN guideline Safer Pre and Post Employer Checks was published during the course of the pilot (December 2007). It describes the procedure for entry of staff into NHSScotland which must be followed in addition to general recruitment policy.

4.72 There are three levels of Disclosure Scotland checks: basic, standard and enhanced. The Guidance indicated that an enhanced check would be required for each HCSW participant, both new and existing employees (whether or not they already had one). However, following advice on the legal requirements governing the disclosure process, this had to be reviewed.

4.73 Clarification of the Disclosure Scotland application procedures took up a lot of NPC and LPC time. It became necessary for the SGHD adviser to clarify the situation with Disclosure Scotland in May-June 2007 with a final formal meeting at SGHD (16 August 2007) and it was unfortunate given Disclosure Scotland's long standing involvement with the pilot planning, that such action was required so late on in the pilot. A further meeting between the National Management Group and a representative from Disclosure Scotland (August 2007) further clarified the necessary requirements ⁵⁶ and an annotated minute was produced. No other written documentation was produced for the pilot; rather LPCs were referred to the specific sections of the standard DS guidance on the website.

4.74 It was now clear that it would not be possible within the law to apply for 'enhanced' for all the kinds of post to be involved in the pilot. Each application should be by individual post and its associated tasks, not by job-group. If the role requires 'direct contact' it would probably require 'enhanced' disclosure, otherwise standard or even basic would be appropriate. A risk assessment was required for each HCSW role to determine the level of contact different types of HCSW have with patients, which then, in turn, determines the level of check to be applied for. The LPCs were advised to check carefully with their own HR department and also with Disclosure Scotland if they were unsure of the appropriate level to apply for.

4.75 LPCs had to make several revisions to the pilot documentation and processes: change all document references from 'enhanced disclosure' to 'appropriate level of disclosure' (especially on consent forms); and post out the DS application form separately rather than include it in the standard information pack, as planned.

4.76 In order to facilitate tracking of applications, pilot sites assigned two new counter-signatories, whose codes were to be used exclusively for the pilot. These were human resources staff, already knowledgeable about DS processes, but this was time consuming as they had to be reregistered for the pilot.

4.77 Each pilot site had an established disclosure process which adhered to local policies for carrying out pre-employment checks. The following process was agreed on for the pilot. A specific part of the pilot consent form was designed to obtain consent to the DS check. On receipt of consent for disclosure the LPC forwarded the DS application form (marked with the correct Disclosure level if possible) and explanatory booklet to the HCSW and the HCSW's manager was required to check the HCSW's identification documents. The completed forms were to be forwarded to the LPC for accuracy checking (normal HR practice to reduce application errors) before forwarding to the HR department where they would be processed and sent to DS. On receipt of the form back from DS the HR department would log the Disclosure outcome and share this with the HCSW.

4.78 LPCs were therefore undertaking some aspects of application processing and checking which would ordinarily fall on HR departments. This was very time consuming, with much chasing up and reissuing of forms and delay due to HCSW errors or failure to return forms.

Numbers of DS applications made by pilot sites

4.79 The numbers going forward to Disclosure Scotland were small, much lower than anticipated at initiation of the pilot, and easily processed by the agency. However, Disclosure Scotland noted that should there be a planned large influx if applications, they might well have to put in more resources (recruit and train staff ⁵⁷, computers).

4.80 The monitoring data confirms that all but three of the 470 recruits to the pilot had given consent for the DS application. 155 forms had not been returned to the LPC. Where forms had been returned the amount of time taken varied widely from 3 days to more than 350 days (where an individual had an initial meeting with a WPS but then observation assessment did not take place for over a year); half the cases took more than 40 days to be returned. There was then great variation across pilot sites in how quickly forms were forwarded to the HR department. In Ayrshire & Arran almost all forms (97%) were forwarded by the LPC mostly within two days and mostly on the same day. For the other two sites only around a fifth were turned round this quickly. 60% of cases were then forwarded by HR to Disclosure Scotland within five days (Ayrshire & Arran 84%, Lothian 79%, Lanarkshire 33%).

4.81 Of the 470 recruits, 70% ( 331) had application forms forwarded to Disclosure Scotland for the pilot. Disclosure Scotland provided detail ⁵⁸ on the 200 applications (43% of recruits) forwarded to DS between January to September 2008 (Ayrshire & Arran 77; Lothian 35; Lanarkshire 88). This was an average of 22 per month but in practice sites tended to send off applications in batches from HR departments. Ayrshire & Arran submitted the first applications from October 2007 and the other two sites from late February 2008. The average by pilot site, for the application to be turned round at Disclosure Scotland (case input to system (case created) to disclosure certificate issued (case completed)) varied from 6 - 8 days.

4.82 More than one in ten (12%, 23) of the 200 applications were returned with errors. Most of the returned forms had one or two errors. The majority of errors were items that the employer would have been responsible for completing (Invoice and Payment methods and CSG errors). Relatively few were HCSW errors (missing names 7, maiden names or where other documentation suggests other names; and Address History errors, 2). This suggests that the systems put in place were correcting most HCSW errors prior to submission to Disclosure Scotland and perhaps further work was needed to ensure LPC/internal HR staff were checking information which was the responsibility of the employer to record.

4.83 Most applications were for 'enhanced' Disclosure and were granted. Just three applying for 'enhanced' came back as 'standard' and these included two Clinical Support Workers working with older people in acute and primary care hospital settings and one physiotherapy assistant in children's services. Disclosure Scotland advised that one hospital based medical laboratory assistant did not come into contact with patients so basic disclosure was applied for and granted. Nine HCSWs were shown as entered on SWISS but monitoring data did not record Disclosure level received.

Dealing with previously undisclosed material

4.84 All pilot sites felt DS checks were important and for some years all had carried out DS checks on new employees and at post changes. Checks on existing employees, for the purposes of the pilot, was a new feature. At the outset, site lead officers were unclear about the number of HCSWs who had not already been subject to Disclosure, or whether some particular categories of worker had routinely been subject to 'Enhanced Disclosure'. They were clear any issues raised by Disclosure checks would go through HR directors who would evaluate the issue but did in fact struggle to recall any specific incidents, concerning HCSWs, where Disclosure checks had raised problems in the past.

4.85 All three pilot sites are satisfied that systems are in place to deal with previously undisclosed material. Lanarkshire has a points based initial 'risk assessment' procedure in place and also felt it important to enhance the initial information given to HCSWs to ensure they fully understood the potential implications of signing up to the pilot and making an application. Lothian held back Disclosure forms while making a decision about the Disclosure process for the pilot; there was a feeling that retrospective checking was having to be addressed in advance of procedures drawn up for the implementation of the Protection of Vulnerable Groups Act. Across the sites, a handful of minor previous convictions have come to light and have been dealt with by Boards. One case illustrated HCSW lack of knowledge about how far back the check might go.

4.86 Initially it was not clear to pilot sites whether HCSWs, who did not sign up to Disclosure Scotland checks, could take part in the pilot. SGHD clarified that HCSWs could take part in testing the achievement of the induction standards, without contributing to the separate pilot aim of testing the burden on Disclosure Scotland. By the end of the pilot there were 41 cases where the Code of Conduct was signed and all assessment completed but the Disclosure Application was not recorded as sent on to Disclosure Scotland as yet. At least two staff had discussed their wish not to forward an application to DS with a manager who advised them they could not be entered onto the occupational list.

4.87 From the surveys, HCSW participants (97%) and non-participants (95%) had no concerns about having a Disclosure Scotland check. Most participants had previously had a Disclosure Scotland check (73%, 114) but a quarter (25%, 39) had not.

The occupational list

4.88 The evaluation aimed to assess the technical aspects of setting up, operating and maintaining a list of HCSWs. It also aimed to assess whether a future list would add value over the implementation of the national standards alone.

Technical aspects of the 'occupational list'

4.89 For the purposes of the pilot, the occupational list is held on the Scottish Workforce Information System ( SWISS), a workforce database for NHSScotland⁵⁹. The SWISS project lead officer was an active member of the 4 Country Steering Group and National Pilot Project Group and continued to advise the pilot.

4.90 It was clarified that the individual Health Board is the data controller for all its own Health Board information and has responsibility for verification pre data entry, entering data, ensuring accuracy and completeness. Each Board would also need to decide processes for keeping information up to date and for any potential removal of names. Boards would need to decide who might access the list locally, what reports might be made and how employee or employer queries about list information might be answered.

4.91 The evaluation found that the first set of these requirements, the practical arrangements, had been tested by the pilot. A drop down list facility has been set up to record successful achievement of the standards ( Annexe I). Local Pilot Coordinators had access permission and guidance to enter data onto SWISS for the purpose of the pilot. Local Boards have facility to generate their own report and SWISS have provided sample reports on the successful 193 HCSWs entered onto the list (Table 5.8). LPCs developed a checklist to ensure all criteria set out in the Guidance are met before an HCSW name is entered.

4.92 In considering potential roll-out of the occupational list it is clear that the physical update and maintenance of the occupational list upon SWISS would be straightforward. In addition, other existing fields could be added to increase the functionality of the list (date of validation, reason and date for end of listing). However a number of key issues would require consideration before any potential roll-out of this pilot list.

4.93 SWISS can only be used for NHS employees and should non- NHS healthcare support workers be included in future then another system would have to be used. SWISS could produce an export file for electronic transfer or re-keying to another system but, as the pilot is voluntary, permission would need to be sought from the already listed HCSWs to do this.

4.94 SWISS currently records achievement of the standards only. In order to facilitate monitoring on a national level it would also be necessary to record the start date of the assessment process (currently recorded on local pilot site monitoring databases only). Without this it would be possible for individuals to keep restarting, but not completing the process, at different Boards.

4.95 For national roll-out a standard format for unique ID would be required (for the pilot each Board took its own approach). A national view would also be required on recording Disclosure Scotland checks ( SWISS currently has a facility to record the level and date of Disclosure check (not the result), but Health Boards have different policies on using this and this field was not updated by participating Health Boards during the pilot).

4.96 For any further development work on the SWISS system a requirements specification would need to be drawn up as soon as possible to allow inclusion into the March 09 or October 09 development plan. Any requirement to add to the existing arrangements for transfer of data to e- KSF would also need to go into the development specification.

Stakeholder views on 'added value' of the list

4.97 The evaluation found that pilot sites had been focused on the earlier stages of the pilot: recruitment, assessment and entering onto their own Board list. At the outset, pilot stakeholders were clear that a full operational year or more was required to see how HCSWs entered onto the list might be managed longer term; particularly to address any implications about information sharing across Boards. There had been insufficient time for any of these issues to arise in practice.

4.98 By the end of the pilot there was still a great deal of uncertainty, and a wide range of opinion from local pilot stakeholders and national key informants as to the added value of having an 'occupational list' once the employer responsibilities (Code of Practice) and healthcare support worker responsibilities (induction standards and the Code of Conduct) were in place. Pilot site stakeholders felt the next step, 'the central list', was for the Scottish Government to consider. During the course of the pilot a number of potential advantages and disadvantages have been aired but in the evaluation's opinion, considerably more detailed work is required before a final decision might be reached.

4.99 A key purpose of the 'occupational list' would be to improve safe recruitment of workers moving across Health Boards or healthcare sectors. Currently we do not have detailed evidence about the number of healthcare support workers who: change jobs within Health Boards; move across Health Boards; move across country boundaries or cross healthcare sectors. Anecdotal evidence is of a largely locally bound workforce with relatively little movement. The SWISS database has the facility to provide reports on numbers crossing these boundaries, but, as yet, this data is largely unpopulated; SWISS was set up in 2004 and the employment starts of the vast majority of long serving HCSWs involved in the pilot will pre-date this ⁶⁰.

4.100 Respondents were very keen that the successful HCSW's effort and stage of development was externally recognised. A certificate was seen as providing an external sign, ' a badge of honour'. A certificate could be used to an HCSW's own advantage; it would be easily portable and transferable across Boards if assessment was nationally implemented to the same level of consistency. The question was then how to ensure the level, as signified by the certificate, was maintained. As seen above (section 4.65) it is suggested that achievement of the standards and Code of Conduct be reviewed annually. A list would provide a further 'audit trail' of competence and positive achievement. It would also allow local Boards to audit the proportion of their workforce at this level.

4.101 However by the end of the pilot the balance of opinion appeared to be weighing towards the greater disadvantages of an 'occupational list' and the real possibility of lack of proportionality of effort expended to outcome achieved. It was felt a list might give an illusion of public protection but that this would only be maintained in reality if the employer follows their own regulations and manages their own staff, to follow safe recruitment practices, including Disclosure Scotland applications and the giving and receiving of proper references. The PIN policy for safe recruitment practice was implemented during the pilot and needed to be followed.

4.102 If an HCSW has met the standards and has a Certificate of achievement, then maintaining the standards would rest upon the Code of Conduct. If it is found that the HCSW does not have the competence then the employer needs to take action to assist the HCSW to make improvements. If a conduct issue arises then the employer needs to follow the standard disciplinary procedures. Stakeholders felt there was a need to ensure that the employer has mechanisms to ensure the HCSW maintains the standards and that possibly this could be under the PDPR. However there was also a perception that if there was no 'strike-off' capability then this would not be regulation.

4.103 The data on the current database, SWISS, legally belongs to each individual Health Board (twenty-two separate NHSScotland employers) and it cannot be shared across Boards.

4.104 The Scottish Social Services Council experience indicates the huge cost and manpower involved in maintaining a registration list. There is a requirement for human rights compliant adjudication and complaints procedures. If there was to be a national HCSW 'occupational list' then there would be a need to be clear on decisions about the level of resource required and who would staff it.

4.105 The currently unanswered question is what proportion of the HCSW workforce will fall under the Protection of Vulnerable Groups (Scotland) Act vetting and barring scheme and to what extent this would fulfil some of the original intentions behind the proposal for an 'occupational list'.

Summary

4.106 It emerged that the WPS role and their enthusiasm was key to the pilot success. Over two hundred WPS were trained, but greater flexibility than envisaged was required to overcome multiple barriers to their engagement with the pilot. More needed to be done in future to provide further support for the role, particularly to prepare those without experience of regulation culture to undertake assessment. WPS (92%) supported the pilot aims but wanted the paperwork streamlined.

4.107 NHSQIS and pilot sites developed a learning and assessment toolkit. Stakeholders were largely supportive of the materials but they required some repackaging and removal of duplication.

4.108 It was not possible to test the potential burden of the induction standards over and above KSF requirements as KSF roll-out was still at an early stage at pilot sites. The pilot found some potential for fit between the induction standards and KSF processes but further more detailed work needed to be carried out.

4.109 The pilot had tested arrangements for Disclosure Scotland applications for HCSW participants in the pilot. The pilot clarified that each application should be by individual post and its associated tasks and not by job-group and also confirmed that procedures for dealing with previously undisclosed material were in place.

4.110 The practical arrangements for a simple list, of HCSWs who have achieved the standards, have been tested on the Scottish Workforce Information System ( SWISS). However further issues would required to be addressed before any potential roll-out of the pilot. Stakeholders continued to maintain widely varying opinions on the added value of a potential 'occupational list'.