manager on-call

Manager On-Call Policy

Version 1.2 December 2018

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Manager On-Call

Target Audience

Who Should Read This Policy

Senior Managers

Directors



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Ref. Contents Page

1.0 Introduction 4

2.0 Purpose 4

3.0 Objectives 4

4.0 Process 4

5.0 Procedures connected to this Policy 8

6.0 Links to Relevant Legislation 8

6.1 Links to Relevant National Standards 9

6.2 Links to other Key Policies 9

6.3 References 9

7.0 Roles and Responsibilities for this Policy 10

8.0 Training 10

9.0 Equality Impact Assessment 11

10.0 Data Protection and Freedom of Information 11

11.0 Monitoring this Policy is Working in Practice 11

Appendices 1.0 Incident Report Form 13

2.0 On-Call Log Recording Form 18



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Explanation of terms used in this policy Out of Hours - These are the hours in which the on-call service will operate and refers to those

hours, which are outside of normal working hours (9.00 a.m. – 17.00 Monday to Friday, except Bank

Holidays).

Therefore, the term out of hours covers weekends and 17.00 hours – 9.00 hours Monday – Friday, plus public holidays when normal working hours are suspended and weekend on-call arrangements

apply

On-Call - When a member of staff is required to be contactable and available in the event of Senior

Management/Director support being needed outside of normal working hours. Note: On-call managers continue to work their normal working hours the following day

On-Duty - When staff members, of any position, work within their paid/contracted hours, usually over a 24-hour period which incorporates rest breaks

Senior Manager - For the purposes of this policy only, a Senior Manager is defined as a Group

Manager or Service Manager

Director - A Director/Group Director of the Trust

Notifying Person - A Manager, team lead, Duty Senior Nurse or the person in charge for an area

during the out of hours period



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1.0 Introduction Black Country Partnership NHS Foundation Trust (The Trust) is committed to the availability of Senior Management or Director support, to staff within its 24 hour services, outside of normal working hours. The operation of 24 hour services can sometimes require the support of Senior Management or Directors, for reporting/authorisation purposes and particularly when incidents occur which may be outside the capability or authority of staff on duty. 2.0 Purpose The provision within the policy covers 365 days per year. The purpose of this policy is to provide guidance to both Senior Managers and Directors on-call, and those staff requiring the support of Senior Management or Directors outside of working hours, on actions to take when undertaking on-call, or contacting the Senior Manager or Director on-call. 3.0 Objectives The objectives of the policy are to:

Provide guidance for Senior Managers or Directors undertaking on-call on what the expectations upon them whilst on-call are

Provide guidance to staff requiring support from Senior Management or Directors out of hours as to the process to contact Senior Management/Directors, and what constitutes a reason to contact Senior Management/Directors out of hours

Provides guidance for staff requiring support from Senior Management/Directors out of hours as to action that should have been undertaken prior to contacting senior management out of hours

Provide a framework for recording all activities call-outs

Provide a framework for assessing the need to call out Senior Management/Directors out of hours

Provide an outline of the expectations upon Senior Management undertaking on-call duties

Outline the implementation of the rota for senior management on-call

Outline the remuneration for undertaking on-call 4.0 Process 4.1 Director On-Call

The Director on-call is available to provide senior representation for the Trust outside of normal working hours. This can involve providing support to the on-call manager and support to staff on duty within 24 hour services

Providing support to the on-call manager in situations where a greater degree of authority is required or where a situation is beyond the capability of the individual on-call

Attending the site of any serious untoward incidents in support of the on-call Senior Manager and staff directly involved in the incident duty

Providing a link to the out of hours services provided by local services

Providing a link to the Health Executive West Midlands out of hours provision via the regional ‘first response’ arrangements, including access to legal advice and NHS West Midlands Emergency Response Management Arrangements (ERMA)



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Acting as a board level representative of the Trust in situations where media contact is required or likely, outside of normal working hours

In line with the Major Incident Policy to act as dictated by the situation, taking strategic oversight of the next steps in the Trust’s incident management

To complete initial and follow-on incident report forms and risk assessment templates included in the On-call Director pack.

4.2 Manager On-Call

Be the first point of contact for teams/services operating outside normal working hours and needing to report in accordance with the on-call policy

Receive verbal ‘over the phone’ reports in line with Trust Policy, e.g. Missing patient, seclusion, serious incidents, sudden, unexpected death, business continuity planning, i.e. disruption to services in the event of fire, flood, disasters, bomb threats, etc.

Provide authorisation in line with Trust/Local Policy, e.g. bank, agency, engineer call out, or where the expenditure exceeds the authority of the nurse in charge

Where Bank or Agency fail to attend for duty after authorisation has been previously agreed by the clinical area, the Duty Senior Nurse/ person in charge; does not need to contact the On-Call Manager for repeat authorisation should they still need to fill that vacant position

Give verbal, over the phone advice and support, to notifying persons when they are dealing with incidents outside of their normal capability

Attend incident scenes, if required, usually in the event of a serious untoward incidents or major disruption, as per the Trust’s Major Incident Plan

Escalate reports of exceptional matters to the Director on-call where appropriate in line with this policy. Provide any follow-up details of the incident, as required to the Director on –call and/or the relevant service manager as the first available opportunity during normal working hours

Routinely attend Manager on-call meetings in order to share information/ raise any issues or matters relating to out-of-hours delivery of services

Record all calls on the on-call recording form in order that information can be collated/monitored and shared by the business and continuity planning group

Contribute to the Managers On-call shared drive, ensuring that the information is up to date and relevant

Complete, in the event of emergency and serious incidents the initial and follow-on ‘incident report forms’ and risk assessment templates included in the on-call manager pack.(see appendices)

4.3 Record Keeping It is a requirement for Notifying persons, Managers on-call and Directors on-call to record and document the date and time of calls received, the decisions made and any responses or actions taken. For routine operational calls i.e. those made by staff for information, clarification or authorisation On-Call managers will use the attached (Appendix 2) On-Call Log Book. For issues that are classed as an incident, the Manager on-call should complete the Incident Report Form (Appendix 1). Manager on-call information packs are available on the on-call managers shared drive



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Records will be retained for a minimum of ten years and may be used for legal purposes in the near future. Records must be destroyed in line with the Trusts corporate record management destruction processes, please refer to the Corporate Record Management Policy for further details.

4.3.1 Notifying Persons The senior person on duty is required to record their out of hour calls in line with their local practice. Completion of datix is required for any incidents associated with actual harm or potential harm to health, safety or welfare as per the Trust’s Incident Reporting Policy. 4.3.2 Manager On-Call The on-call manager is required to complete an ‘on-call log’ following each call. The ‘on-call log’ is available electronically. In the event of a major or serious incident that may be disruptive to service delivery a series of action cards, Incident report forms, risk assessments and follow-on records are provided, in accordance with the business continuity and emergency planning policy. Upon receipt of calls related to serious incidents such as, fire, flood, explosions, bomb/security threats, and lock down, the manager on-call contacts the Director on- call immediately. (See appendices 1, 2, 3) In order to co-ordinate a response, identify levels of escalation, and record actions taken the manager on-call will:

Complete the action card

Complete the risk assessment

Maintain a log of all subsequent/follow-up calls/actions/decisions

Pass the above records documentation on to the business continuity and planning administrator the next morning or at the first available opportunity

4.3.3 Director On-Call In order to co-ordinate the initial response to an incident on behalf of the Trust and to determine the level of response the Director on-call will refer to the relevant documentation and actions in line with Trust Business and emergency planning policy. 4.4 Contacting the Manager On-Call 4.4.1 Prior to Contacting the Manager On-Call The notifying person needs to ensure:

The problem or issue is clearly identified

An assessment of any actual or potential risk has been undertaken

All possible alternatives / options to resolve the issue have been pursued, considered and implemented as appropriate to the situation

4.4.2 Upon Contacting the Manager On-Call The notifying person to state:

Their full name and location/team

Description of the problem/issue

Explanation of any risks, as relevant



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Description of the actions taken and why the situation remains unresolved

The purpose of the call and what is required from the manager on-call 4.4.3 After Contacting the Manager On-Call The notifying person will need to:

Record details of the discussion and what was agreed/decided in the relevant documentation for that area

Record incidents electronically, (Datix) as per Trust policy

Ensure the service manager for that area is fully informed the following day, or at the first available opportunity

4.5 Contact details The manager on-call can be contacted by the notifying person via: Penn Hospital Reception Tel: 01902 444141. The Director On-call can be contacted by the manager on-call via: Penn Hospital Reception Tel: 01902 444141. 4.6 On-Call Rota

4.6.1 On-Call Rota Administration The rota is based for the time period:

Monday to Friday 5.00pm-9.00am next working day

Saturday 9.00am – 9.00am Sunday

Sunday 9.00am – 9.00am Monday

The Manager On-call rota will be developed centrally and circulated to all senior managers and directors and Penn Reception. Senior managers will be expected to make themselves available during their period on-call. If senior managers are unavailable for their allocated period, they are responsible for ensuring their own cover arrangements with colleagues.

It is the responsibility of the senior manager making the change to the rota to ensure that this is communicated centrally and to Penn Reception. 4.6.2 Bank/ Public Holidays For on-call being undertaken over a Bank Holiday, the On-call Manager will take up the on-call with effect from 9.00 a.m. on the morning of that bank/public holiday. For example: Where the Bank Holiday falls on Monday, the on-call manager will pick up on-call from Monday morning and remain on-call until 9.00 a.m. on the Tuesday morning. Where a Bank Holiday falls on a Friday, the on-call manager will begin from 9.00 a.m. on the Friday morning until 9.00 a.m. on Saturday morning.

Over the Christmas period, beginning the Monday prior to Christmas Day, the Director on Call rota will be based on each manager being on-call for one day.



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The manager on-call covering the Bank Holiday period is entitled to an additional day off. 4.7 Senior Manager On-Call Meeting The Senior Manager’s on-call meeting is a sub-group reporting into the Business Continuity Meeting, and it is a requirement for all senior managers on-call to attend. The purpose of the meeting is:

Information sharing

To change rota as required (ensuring that the main/ agreed changes are done centrally at Penn)

To debrief, offer mutual support

To discuss and learn from exceptional issues

To discuss, themes and issues arising from on-call

To discuss and agree process including escalation, communication, systems and aspirations

4.8 Payment The Senior Manager On-call rota requires that all Group Managers and Service Managers undertake on-call duties. Payment for these on-call duties will be made in line with Agenda for change as follows:

Frequency of On-call Payment as percentage of salary

1 in 3 or more frequent 9.5%

1 in 6 or more but less than 1 in 3 4.5%

1 in 9 or more but less than 1 in 6 3.0 %

1 in 12 or more but less than 1 in 9 2.0%

Less frequently than 1 in 12 By local agreement

Within the Trust, it has been agreed locally that for the less frequently than 1 in 12, payment will be at 1%. Senior Managers who are called into work during a period of on-call will receive payment for the period that they are required to attend, including any travel time. This will be claimed by the completion of an appropriate time sheet. Where senior managers are required to undertake work continuously on a specific task from home, or are involved in a telephone conversation, which exceeds 30 minutes duration, will receive payment for this period. This will be claimed by the completion of an appropriate time sheet. 5.0 Procedures connected to this Policy There are no procedures connected to this policy. 6.0 Links to Relevant Legislation Equality Act 2010 Equality Act came into force on 1 October 2010 and brought together over 116 separate pieces of legislation into one single Act to provide a legal framework to protect the rights of individuals and advance equality of opportunity for all. The Act simplifies, strengthens and harmonizes the current legislation to provide a new



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discrimination law which protects individuals from unfair treatment and promotes a fair and more equal society.

6.1 Links to Relevant National Standards Medical and Dental Whitley Council Handbook 2008 (as amended annually) This Handbook is published on the NHS Employers Website amended whenever new agreements are reached in the NHS Staff Council. Amendments to the Handbook are published in numbered pay and conditions circulars which set out details of the changes, including the effective date(s) of changes to pay and conditions. 6.2 Links to other Key Policies Incident Reporting Policy The purpose of this policy is to make clear the system used for reporting incidents involving patients, staff and others undertaking activities on behalf of the Trust. Business Continuity Management Policy Although the Trust is classed as a ‘category 1’ responder under the Civil Contingencies Act 2004, this is by definition due to its attainment of Foundation Trust status. Thus, within major incident planning and response arrangements the Trust is not expected to play a major role within a traditional ‘major incident’ scenario. The focus for the Trust should therefore be on developing and embedding appropriate business continuity arrangements to ensure it can effectively meet the challenges of incidents that can disrupt the continuity of its critical and essential services under the NHS England Emergency Preparedness Framework 2013. The aim of this policy is to provide an effective business continuity framework which will allow the Trust to meet its regulatory obligations. Anti-Fraud, Bribery and Corruption Policy The aim of this policy is to set out clearly for staff, the framework and controls in place for dealing with all forms of detected or suspected fraud, bribery and corruption. Record Management (Corporate) This document sets out a framework within which the staff responsible for managing the Trust’s corporate records can develop specific policies and procedures to ensure that records are managed and controlled effectively, and at best value, commensurate with legal, operational and information needs. This policy supersedes and replaces all existing policies within the Trust relating to Corporate Records Management (including those services that the Trust has inherited as a consequence of Transforming Community Services). 6.3 References

Medical and Dental Whiteley Council Handbook (2008) as published via NHS Employers



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7.0 Roles and Responsibilities for this Policy

Title Role Key Responsibilities

Director of Operations Executive Lead - Overall responsibility for business continuity - Lead Responsibility for the implementation and application of the Policy

Trust Board Strategic - Strategic overview and final responsibility for setting the direction for Manage On-Call Policy -

Business Continuity and

Emergency Preparedness Group

Responsible - Responsible for the approval and implementation of the policy and managerial oversight of on-call provision

Notifying Person Implementation - Ensure that risk assessments/ resolutions have been actioned or implemented to help inform decision-making, prior to

contacting the on-call Manager - Escalate issues as and when appropriate after following appropriate pathways and structures

- Contact Manager on-call as required, in line with the on-call policy process

Directors Operational - undertake on-call as part of a Director on-call Rota - Share information as appropriate

- Implement the Major Incident plan as required

Senior Managers Operational - Undertake on-call as part of management duties - Adhere to the on-call rota

- Be responsible for own cover arrangements, and that any changes to on-call rota are communicated to Penn Reception - Complete documentation as required for on-call and submit to administration support

- Share information as appropriate - Routinely attend Senior Manager on-call meetings

All Staff Adherence - Escalate issues that occurs after 5pm or over the weekend to the notifying person in line with the on-call policy process

- Undertake a risk assessment of issues and look to resolve issues prior to making a decision whether to contact the notifying person

8.0 Training

What aspect(s) of this policy will

require staff training?

Which staff groups require this

training?

Is this training covered in the Trust’s Mandatory and Risk

Management Training Needs Analysis document?

If no, how will the training be delivered?

Who will deliver the training?

How often will staff require

training

Who will ensure and monitor that staff have

this training?

Managing requests for

cover

Directors/Senior Managers

No, Staff will receive specific training in relation to this policy

where it is identified in their individual training needs analysis as

part of their development for their

particular role and responsibilities

Internally Human Resources Staff

As required Workforce Development Group



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9.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email [email protected]

10.0 Data Protection and Freedom of Information Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4% of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data. The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities; unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act. All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team. 11.0 Monitoring this Policy is Working in Practice

What key elements will be monitored?

(measurable policy objectives)

Where described in

policy?

How will they be monitored?

(method + sample size)

Who will undertake this

monitoring?

How Frequently?

Group/Committee that will receive and

review results

Group/Committee to ensure actions

are completed

Evidence this has

happened

Serious/ major incidents are

responded to

in an effective, efficient manner with minimum

disruption to 24 hour services

4.0 Process Minutes of the Business

continuity planning group

Business Continuity

Steering Group

Following a

major incident

Business Continuity

Steering Group/

Senior Manager’s On-call meeting

Business Continuity

Steering Group/


Minutes of

meeting/

Action Plan signed off

mailto:[email protected]

http://simple.wikipedia.org/wiki/Information

http://simple.wiktionary.org/wiki/right



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24-hour services run

effectively and efficiently

out-side normal working hours

4.0 Process Manager On-call Audit

report

Business Continuity

Steering Group

Annually Business Continuity

Steering Group/


Business Continuity

Steering Group/


Minutes of

meeting/

Action Plan signed off



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Appendix 1

Incident Report Form

TO BE COMPLETED WHEN USED BY ON-CALL PERSONNEL

On-call duty

period (dates)

Call received no (1, 2 etc.)

during this duty period

Form completed by

Reporting Unit

Date of initial call Time of initial call

Call made by Return tel. no

This is my Incident Report Form No (1, 2 etc.) for this Incident

Incident Report at Date: Time:

Brief description of incident

Further specific information (the following prompts are guidelines only)

WHERE THIS IS A FOLLOW ON REPORT AND THERE IS NO CHANGE SINCE LAST REPORT PLEASE ANNOTATE THE APPROPRIATE SECTION 'AS LAST REPORT'

Exact location of the incident?

Which Team(s)/Department(s) are currently involved?

Which Group(s) are



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currently involved?

Further specific information continued

Are there any hazards to patients, staff, responders or to members of the public?

Have any external agencies (e.g. emergency services, other Trusts) been notified?

What are the current risks, if any, to services?

Are there any reputational risks to the Trust?

What is the current or anticipated future level of media interest (local/regional/national)?

Is the incident likely to invoke political interest (local/regional/national)?

Any other relevant information?



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Description of advice given / action taken / decisions made

Follow-up Incident Report Form to be completed? YES / NO

Escalate? YES / NO

Record rationale for escalation below:

De-escalate? YES / NO

Record rationale for de-escalation below:

Signature:

Date completed: Time completed:

Incident Risk Assessment Template



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Use one template for each risk

This is template no (1, 2, etc.) of for my Incident Report Form number

Completed by (name).

Description of risk Level of Risk = Consequence x Likelihood

Lik

elih

oo

d o

f o

ccu

rren

ce Almost

certain 5 10 15 20 25

Likely 4 8 12 16 20

Possible 3 6 9 12 15

Unlikely 2 4 6 8 10

Rare 1 2 3 4 5

Insignificant Minor Moderate Major Catastrophic

Level of Consequence (Impact or Severity)

KEY KEY KEY KEY

Range 16 – 25 (High)

Un-acceptable

risks

Range 10 – 15

(Moderate) Un-

acceptable risks

Range 6 - 9 (Low)

Acceptable risks

Range 1 – 5 (Very

Low) Minor acceptable

risks

Rate the described risk (Consequence x Likelihood = Final Score)

Consequence Likelihood Initial Score/Level of Risk

Detail controls for this risk that are already in place (if any)

List and number further actions required to reduce the risk

Actions allocated to (indicate number if multiple individuals) Deadline for actions to be competed

Rate the anticipated residual risk once actions above completed (Consequence x Likelihood = Final Score)

Consequence

Likelihood Residual Score/Level of Risk


Version 1.2 December 2018 17

Incident Report Form Continuation Sheet


Appendix 2

On-Call Log Recording Form

Name of Manager ……………………… On-Call Period - From………………To …………..……. Sheet No. …………….

Entry No.

Date Time (24hr)

Information / Message to Manager

From Contact Details

Action by Manager Contact Details

Time (24hr)

Initial


Policy Details

* For more information on the consultation process, implementation plan, equality impact assessment, or archiving arrangements, please contact Corporate Governance

Review and Amendment History

Version Date Details of Change

1.2 Dec 2018

Policy reviewed with minor word amendments made and changes to the On-Call Rota Administration- page 4, 4.1 taken out Board Level; page 7, the time table should have been 5am to 9am Saturday and updated 4.3 with Trust’s retention timeline.

1.1 Nov 2015 Minor amendments and new policy format

1.0 Aug 2013 New Policy for BCPFT

Title of Policy Manager On-Call Policy

Unique Identifier for this policy BCPFT-HR-POL-22

State if policy is New or Revised Revised

Previous Policy Title where applicable n/a

Policy Category Clinical, HR, H&S, Infection Control etc.

Human Resources

Executive Director whose portfolio this policy comes under

Director of Operations

Policy Lead/Author Job titles only

Head of Operations Senior Human Resources Manager

Committee/Group responsible for the approval of this policy

Continuity and Emergency Preparedness Group

Month/year consultation process completed *

December 2018

Month/year policy approved December 2018

Month/year policy ratified and issued January 2019

Next review date December 2021

Implementation Plan completed * Yes

Equality Impact Assessment completed * Yes

Previous version(s) archived * Yes

Disclosure status ‘B’ can be disclosed to patients and the public

Key Words for this policy

Incident report form, On-Call Log Recording Form, Out of hours, On-duty, Director on-call, Manager on-call, Record keeping, On-call rota

manager on-call

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