Staff & Recruitment

Introduction

The Capability Policy is designed to deal with those cases where the employee is lacking in some area of knowledge, skill or ability resulting in a failure to be able to carry out the required duties to an acceptable standard.  The expectation is that where this standard is not met, this will be addressed through a supportive, two way framework where employees will be offered support, encouragement, guidance and training to improve their work performance.

The policy should not be applied in the issues of conduct and a distinction must be drawn between a genuine lack of capability and unsatisfactory performance that is attributable to a wilful refusal on the part of the employee to perform to the standards of which they are capable.  This should be dealt with under the Board’s Disciplinary Procedures.

This policy should not be applied in the cases of issues of capability related to ill health impacting on attendance.  However, it does apply in the case of issues of capability related to ill health where such issues impact on performance (as opposed to attendance).

General Principals

All employees must be made aware of the standards of performance required and of the need to perform acceptably to such standards.

Issues of capability must be addressed at the earliest opportunity and (except in more serious cases) on an informal basis in the first instance before resorting to the formal procedures.

Issues of capability must be addressed fairly, consistently and confidentially, irrespective of the position/level within the Board of employees with whom such matters arise.

A failure to deal with such concerns may adversely affect colleagues and standards of patient care and ultimately the efficiency and quality of the service.

Issues of capability must be addressed in a supportive manner with every opportunity to improve within the current role being offered, and where such improvement is not achievable and sustainable, considering exploration of suitable alternative employment opportunities.  Termination of employment on the grounds of capability must only be a last resort

Identifying a Performance Issue

The key questions to determine whether there is a capability issue are:

• What are the indications that the employee is not meeting the requirements of the job?
• Are there factual grounds to indicate inadequate performance, such as not meeting objectives or failure to deliver the requirements of the job?

Some of the common indicators may include:-

• Complaints about, or criticism of, the employee’s work from colleagues, patients or visitors.
• There may be factual grounds to indicate unsatisfactory performances such as poor results.
• The manager’s own observations of the employee’s performance may give rise to concerns.
• The employee requesting help to overcome a problem.

 The main factors that can affect performance include:- 

• Lack of awareness/understanding of the standards or performance required.
• ill health
• Difficulties in personal circumstances
• Organisational Change
• Bullying or harassment
• Inappropriate or ineffective recruitment and selection processes

A combination of more than one of the above factors.

On the basis of the issues or concerns identified, it may be necessary to put in place additional supervision in order to mitigate risk, whilst any necessary investigation is undertaken and in advance of agreeing a supported improvement plan.  It may ultimately be necessary to place an employee on a short period of paid leave until such times as a supported improvement plan can be agreed and implemented. 

This should be as a last alternative and for as short a period as possible, all effort being made to identify alternatives which will allow the employee to remain at work (through the use of alternative duties or additional supervision).

Information Discussion

Prior to any consideration in terms of the Capability Policy, early intervention is encouraged when poor performance is identified, enabling a supportive approach to be taken.  This can involve short informal discussions between the manager and employee to discuss shortfalls in performance as they arise, identifying solutions and support to ensure that the employee is provided with every opportunity to improve their performance.

Early intervention should ensure that every effort is made to assist the employee and encourage their improvement.

Informal Meeting

Where a potential performance/capability issue is identified, the manager should arrange to meet with the member of staff (verbally) for an informal, private one to one discussion, offering advice and guidance on expected future performance and to support the employee in achieving the required standards.  The employee should be clear on the purpose of the meeting and the issues to be discussed.

Whilst there is no requirement to have a staff side representative in attendance at this informal stage, the employee should be provided with adequate notice to allow them to arrange a representative if they so wish.

The key issues to be discussed at this meeting should be:-

• The standards of performance expected in the role.
• The particular performance concerns and whether the employee acknowledges and understands that there is a problem. 
• Possible contributing factors as detailed in Section 3.
• Possible solutions or a range of solutions
• Agree a supported improvement plan with specified time limits.

The discussion requires to be sensitively handled, free from interruptions in an atmosphere of trust and open discussion.  Employees must be encouraged to be entirely open and honest in exploring these issues.  Managers must bear in mind that the aim is to assist the employee to improve their work performance to an acceptable standard.

It is imperative that the problem(s), as perceived by the manager and employee, are fully explored and established and the issues are understood by all.

Outcome of Informal Meeting

The outcome of the meeting should be confirmed by the manager in writing to the employee, normally within 5 working days, and should include the following:-

• Details of the issues discussed
• The agreements reached
• A copy of the supported improvement plan (if completed)
• The timescales during which satisfactory improvement is expected to be reached and maintained.
• The employee should also be advised of the possibility of progression to the formal stages of the policy should there be an inadequate improvement within the agreed timescales.
• A copy of NHS Greater Glasgow and Clyde’s Capability Policy

 Two copies of the letter should be issued to the employee, along with an acknowledgement slip.  The employee should sign and return the acknowledgement slip along with one copy of the letter, to be retained in their personal file.  They should retain the other copy for their own information.

Supported Improvement Plan / Action Plan

A key outcome of the informal discussion, either during the meeting or after the meeting, should be the development of an appropriate plan to support the individual in improving their performance.

The Supported Improvement Plan should contain the following:-

• The nature and extent of the unsatisfactory performance.
• The standards of performance required.
• How reaching and maintaining such standards is expected to be evidenced.
• Support mechanisms which have been put in place (whether solely for the supported improvement process or as permanent arrangements).
• Who will be mentoring/supporting the employee?
• The timescales during which satisfactory improvement is expected to be reached and maintained.

It may be necessary during a Supported Improvement Plan to amend the employee’s duties to enable a focus on certain duties or to ensure a greater degree of supervision.  However, it should be made clear that successful completion of the Supported Improvement Plan will require the employee to reach and maintain the required standards across their full range of work duties and without the need for an increased level of supervision.  Any supports identified as ‘reasonable adjustments’ under the Equalities Act should be identified as sustainable during the course of the employee’s employment as appropriate.

The Supported Improvement Plan should be signed and dated by the manager and employee to confirm their agreement.  However, a failure by the employee to agree the contents of the plan does not prevent its implementation.

The mentor/manager should meet with the employee, at least on a weekly basis, during the period of supported improvement in order to discuss progress and provide any additional support.  The Monitoring Framework documentation provides appropriate mechanism to facilitate this process.

These meetings, including the details discussed and any additional support provided should be clearly documented in the log within the Monitoring Framework and should be signed by both the mentor/manager and the employee.

NOTE: The template provided for the Supported Improvement Plan/Action Plan can be used at all stages of the Capability Process.

Monitoring and Review

The timescales for monitoring and review would normally be agreed to take place over a four to twelve week period.  The length of this will depend on a number of variable factors and these must be fully considered before determining the timescales:-

• The nature of the performance issue.
• How long it will take to complete the Supported Improvement Plan.
• The availability of the Mentor.
• Any planned periods of annual leave

A similar process for monitoring and review can be adopted for all stages of the Capability Process.

Informal Stage – Interim Review Meeting

It may also be appropriate to consider a Mid-Review meeting to take place during the Supported Improvement Plan.  This will provide a defined period for the manager and employee to review and discuss progress, make any amendments to the plan, introduce additional support and potentially consider the extension of the timescales if appropriate.

Final Informal Review Meeting

The final review meeting will take place on completion of the agreed timescale and the employee should be verbally notified of the date and time of the meeting and should be clear on the matters to be discussed. 

The following areas should be discussed:

• The objective review of the employee’s progress against the Supported Improvement Plan.
• Feedback from the employee in terms of their progress and also examples/evidence of those improvements.
• Discussion and a decision on the next step to be taken.

Possible outcomes will include:

• The employee has improved their performance and no further action requires to be taken.  Normal supervision and performance management processes will continue.
• The employee has improved to an extent and the Supported Improvement Plan should be extended to provide the opportunity for further improvement. The amended timescales should be highlighted to the employee, along with the outstanding objectives to be addressed.
• The employee has been unable to improve their performance in line with the required standard and should progress to the formal stage of the capability process.

Outcome of Final Review Meeting

The outcome of the meeting should be confirmed by the manager in writing to the employee, normally within 5 working days, and should include the following details:-

• Details of the issues discussed
• The employee’s position in terms of completion of the Supported Improvement Plan.
• The employee should also be advised clearly of the decision taken at the meeting as detailed above.

Two copies of the letter should be issued to the employee, along with an acknowledgement slip.  The employee should sign and return the acknowledgement slip along with one copy of the letter, to be retained in their personal file.  They should retain the other copy for their own information.

Escalation to Formal Stage 1 will take place when the informal stage has not resulted in the required improvement in performance despite having being given initial, informal guidance and support.  This stage may also be used in more serious circumstances when a more formal approach is required. 

Matters should not be progressed to the formal stages if it is established that the employee has not had the necessary training, guidance and support required to undertake the job. 

The process for undertaking Formal Stage 1 of the Capability Policy is noted below:

Arrange Formal Capability Meeting – Stage 1

A meeting will be arranged with the employee and at least five working days’ notice should be provided of the meeting.

The letter inviting the employee to the meeting should include the following information:

• The date, time and location of meeting
• The stage of the Capability Policy being used
• Clear details of performance concerns
• All necessary supporting documentation (including details of any informal approach already undertaken)
• Who will be attending the meeting
• The employee’s right to be represented
• An indication of the possible outcomes of the meeting.

The letter should also highlight that the NHS Greater Glasgow and Clyde Capability Policy is available on HR Connect.

Preparation for Formal Capability Meeting – Stage 1

Preparation is crucial to a successful capability meeting, including gathering all relevant information and documentation relating to the areas of the employee’s work performance that require improvement.  It may also be helpful to consider how these areas of concern relate to the employee’s Knowledge & Skills Framework outline for the post they are undertaking and how these may be addressed.

Format of Capability Stage 1 Meeting

The following areas should be discussed and agreed at the meeting:

• The employee should be told clearly and precisely the areas identified in which there are concerns over their performance and the improvement in work standard which is required.
• The employee should be given an opportunity to respond to the points made and to explain any difficulties which may be impacting on their performance.
• There should be a discussion about the ways and means by which the desired improvement may be achieved.
• A Supported Improvement Plan (detailed at Section 4.3) should be agreed that details the improvement required, what support mechanisms will be introduced to aid this process and realistic timescales should be set.
• Consideration should also be given as to whether mentoring, training or coaching would be appropriate and included as part of the Supported Improvement Plan.
• Discuss whether there are any underlying health issues or personal problems that may have affected performance.
• The date when the employee’s performance will be reviewed again (a formal review meeting should take place mid-way and at the end of the agreed timescale set).
• Possible outcomes if the required improvement is not achieved within the agreed timescales.

As with the Informal Stage Meeting, the discussion requires to be sensitively handled, free from interruptions in an atmosphere of trust and open discussion.  Employees must be encouraged to be entirely open and honest in exploring these issues.  Managers must bear in mind that that the aim is to assist the employee to improve their work performance to an acceptable standard.

It is imperative that the problem(s), as perceived by the manager and employee, are fully explored and established and the issues are understood by all.

Outcome from Capability Formal Stage 1 Meeting

The outcome from this meeting should be formally recorded in a letter to the employee within 5 working days of the meeting including a copy of the agreed action plan, either signed at the meeting or to be signed.

The letter will include the following:

• Clear details of the performance concerns
• The improvement(s) required
• An agreed Supported Improvement Plan to achieve improvement
• Details of how the plan is going to be monitored, providing dates for review meetings if agreed
• Confirmation of the timescales
• Potential outcomes including escalation to Stage 2 of the process.

Two copies of the letter should be issued to the employee, along with an acknowledgement slip.  The employee should sign and return the acknowledgement slip along with one copy of the letter, to be retained in their personal file.  They should retain the other copy for their own information.

Monitoring and Reviewing – Formal Stage 1

The timescales for the process of monitoring and review can vary from case to case, but in all formal cases it is important to arrange a mid-way formal meeting to review and assess the progress of the employee at an early stage.

Formal Stage – Mid-Way Formal Review Meeting

The employee should be formally invited to this meeting and provided with at least 5 working days’ notice.

The letter should include the following information:

1. The date, time and location of meeting
2. Who will be in attendance (the manager may wish to consider asking the mentor to be in attendance if one was identified)
3. The right to be represented at the meeting
4. Confirmation that the purpose of the meeting is to review the current Supported Improvement Plan/Action Plan in place and whether any adjustments are required at this point in time

At this meeting the manager should review the employee’s performance to date and constructive feedback should be given. The employee will also be provided with the opportunity to give feedback on the benefits of any support mechanisms provided. Management and the employee should consider whether any further supports or adjustments are required to be made to the Supported Improvement Plan/Action Plan. It should be reiterated to the employee what the next steps may be if they do not meet all objectives within their agreed Supported Improvement Plan/Action Plan at the end of their review period.

The outcome from the Formal Mid-way Review Meeting should be formally recorded in a letter to the employee within 5 working days of the meeting.

Final Formal Review Meeting – Stage 1

A letter should be sent to the employee formally inviting them to this meeting and providing at least 5 working days’ notice.

The letter should include the following information:

• The date, time and location of meeting
• Who will be in attendance (the manager may wish to consider asking the mentor to be in attendance if one was identified)
• The right to be represented at the meeting
• Confirmation that the purpose of the meeting is to review the current Supported Improvement Plan/Action Plan.

At the Final Capability Formal Stage 1 Review Meeting the manager is required to identify whether the desired improvement has been achieved by the employee. The manager will review the Supported Improvement Plan/Action Plan and consider the information provided by the mentor (if one had been identified) and feedback from the employee to allow them to make this decision.

At this meeting the employee will then be advised of the following potential outcomes:

• The employee has improved their performance and no further action requires to be taken.  Normal supervision and performance management processes will continue.
• The employee has improved to an extent and the Supported Improvement Plan should be extended to provide the opportunity for further improvement.  The amended timescales should be highlighted to the employee, along with the outstanding objectives to be addressed.
• The employee has been unable to improve their performance in line with the required standard and should progress to Formal Stage 2 of the capability process.

The outcome from the Final Capability Formal Stage 1 Review Meeting should be formally recorded in a letter to the employee within 5 working days of the meeting.

The letter should include the following:

• Details of the issues discussed
• Confirmation of the employee’s position in terms of completion of the Supported Improvement Plan.
• Details of the outcome – performance has improved, performance has improved to an extent or performance has not improved to the extent required, therefore referred to Stage 2.

 Two copies of the letter should be issued to the employee, along with an acknowledgement slip.  The employee should sign and return the acknowledgement slip along with one copy of the letter, to be retained in their personal file.  They should retain the other copy for their own information.

Please note that if the outcome is that the necessary improvement has been achieved, then the manager should ensure that all capability documentation is removed from the employee’s file 6 months after the date of the outcome letter as long as there have been no further cause for concerns. It is best practice for the manager to inform the employee when such paperwork has been removed.

Formal Stage 2 of the capability process should be used if the desired improvement has not been achieved by the employee at Formal Stage 1. This stage can also be used where evidence exists that there is a genuine factor which renders an employee incapable of carrying out their current role, and all parties are in agreement that redeployment is the only option.

Escalation to Formal Stage 2 will take place when Formal Stage 1 has not resulted in the required improvement in performance despite having been given guidance and support.  This stage may also be used in more serious circumstances when a more formal approach is required. 

Arrange Formal Capability Meeting – Stage 2

A meeting will be arranged with the employee and at least five working days’ notice should be provided of the meeting.

The letter inviting the employee to the meeting should include the following information:

• The date, time and location of meeting
• The stage of the Capability Policy being used
• Clear details of performance concerns
• All necessary supporting documentation (including details of the full capability process to date)
• Who will be attending the meeting
• The employee’s right to be represented
• An indication of the possible outcomes of the meeting.

The letter should also highlight that the NHS Greater Glasgow and Clyde Capability Policy is available on HR Connect.

Preparation for Formal Capability Meeting – Stage 2

Preparation is crucial to a successful capability meeting, including gathering all relevant information and documentation relating to the areas of the employee’s work performance that require improvement.  It may also be helpful to consider how these areas of concern relate to the employee’s Knowledge & Skills Framework outline for the post they are undertaking and how these may be addressed.

Format of Capability Meeting – Stage 2

The meeting should be chaired by the identified manager and the following areas should be covered at the meeting:

• The employee should be told clearly and precisely the areas identified in which their performance is still unsatisfactory and the improvement in work standard required
• Previously identified support measures from Stage 1 should be reviewed and a discussion should take place as to whether they should continue or if any additional measures should be added to the Supported Improvement Plan.
• The employee should be given an opportunity to respond to the points made and provide any other relevant information.
• The Supported Improvement Plan should be reviewed and agreed with clear details of the improvement required, what support mechanisms will be introduced to aid this process, and realistic timescales should be set
• Consideration should also be given as to whether additional mentoring, training or coaching would be appropriate and included as part of the Supported Improvement Plan.
• Discuss whether there are any underlying health issues or personal problems that may have affected performance
• The date when the employee’s performance will be reviewed again (a formal review meeting should take place mid-way and at the end of the agreed timescale set)
• Advise the employee of likely outcomes if they fail to improve to the required standard, including the possibility of disciplinary action and potentially dismissal.

The discussion requires to be sensitively handled, free from interruptions in an atmosphere of trust and open discussion.  Employees must be encouraged to be entirely open and honest in exploring these issues.  Managers must bear in mind that that the aim is to assist the employee to improve their work performance to an acceptable standard.

It is imperative that the problem(s), as perceived by the manager and employee, are fully explored and established and the issues are understood by all.

Outcome from Capability Formal Meeting – Stage 2

The outcome from this meeting should be formally recorded in a letter to the employee within 5 working days of the meeting including a copy of the agreed action plan, either signed at the meeting or to be signed.

The letter will include the following:

• Clear details of the performance concerns
• The improvement(s) required
• An agreed Supported Improvement Plan to achieve improvement
• Details of how the plan is going to be monitored, providing dates for review meetings if agreed
• Confirmation of the timescales
• Potential outcome of failing to reach and maintain the required standards, including the potential for referral for consideration under the Board’s Disciplinary Policy.

Two copies of the letter should be issued to the employee, along with an acknowledgement slip.  The employee should sign and return the acknowledgement slip along with one copy of the letter, to be retained in their personal file.  They should retain the other copy for their own information.

Monitoring and Reviewing – Formal Stage 2

The timescales for the process of monitoring and review can vary from case to case, but in all formal cases it is important to arrange a mid-way formal meeting to review and assess the progress of the employee at an early stage.

Formal Stage – Mid-Way Formal Review Meeting

The employee should be formally invited to this meeting and provided with at least 5 working days’ notice.

The letter should include the following information:

• The date, time and location of meeting
• Who will be in attendance (the manager may wish to consider asking the mentor to be in attendance if one was identified)
• The right to be represented at the meeting
• Confirmation that the purpose of the meeting is to review the current Supported Improvement Plan/Action Plan in place and whether any adjustments are required at this point in time

At this meeting the manager should review the employee’s performance to date and constructive feedback should be given. The employee will also be provided with the opportunity to give feedback on the benefits of any support mechanisms provided. Management and the employee should consider whether any further supports or adjustments are required to be made to the Supported Improvement Plan/Action Plan. It should be reiterated to the employee what the next steps may be if they do not meet all objectives within their agreed Supported Improvement Plan/Action Plan at the end of their review period.

The outcome from the Formal Mid-way Review Meeting should be formally recorded in a letter to the employee within 5 working days of the meeting.

Final Formal Review Meeting – Stage 2  

A letter should be sent out to the employee inviting them into the above meeting. The employee should be given at least 5 working days’ notice.

The invite letter should include the following information:

• The date, time and location of meeting
• Who will be in attendance (the manager may wish to consider asking the mentor to be in attendance if one was identified)
• The right to be represented at the meeting
• Confirmation that the purpose of the meeting is to review the current Supported Improvement Plan/Action Plan in place and confirm whether the desired improvement has been achieved or whether further action is required under NHS Greater Glasgow and Clyde’s Disciplinary Policy

At this meeting the manager is required to identify whether the desired improvement has been achieved by the employee. The manager will review the Supported Improvement Plan/Action Plan and consider the information provided by the mentor (if one had been identified) and feedback from the employee to allow them to make this decision.

The employee will then be advised of the following potential outcomes:

• The employee has improved their performance and no further action requires to be taken.  Normal supervision and performance management processes will continue.
• The employee has improved to an extent and the Supported Improvement Plan should be extended to provide the opportunity for further improvement.  The amended timescales should be highlighted to the employee, along with the outstanding objectives to be addressed.
• That the necessary improvement has not been achieved therefore the employee will be advised that further action will be required under NHS Greater Glasgow and Clyde Disciplinary Policy and Procedure

The outcome from the Final Capability Formal Stage 2 Review Meeting should be formally recorded in a letter to the employee within 5 working days of the meeting.

The letter should include the following:

• Details of the issues discussed
• Confirmation of the employee’s position in terms of completion of the supported improvement plan.
• Details of the outcome – either performance has improved or performance has not improved so further action is required under the NHS Greater Glasgow and Clyde Disciplinary Policy.

Two copies of the letter should be issued to the employee, along with an acknowledgement slip.  The employee should sign and return the acknowledgement slip along with one copy of the letter, to be retained in their personal file.  They should retain the other copy for their own information.

Please note that if the outcome is that the necessary improvement has been achieved, then the manager should ensure that all capability documentation is removed from the employee’s file 6 months after the date of the outcome letter as long as there have been no further cause for concerns. It is best practice for the manager to inform the employee when such paperwork has been removed.

Referral to be Considered under the disciplinary policy and procedure

A management statement of case should be prepared, summarising the full details of the employee’s progress through the informal and formal Capability process.  This should include:-

• Background of employment history
• Initial discussions and concerns
• Details of the informal process, including support, training, guidance offered and the Supported Improvement Plan agreed.
• Details of the Stage 1 process, including support, training, guidance offered and the Supported Improvement Plan agreed.
• Details of the Stage 2 process, including support, training, guidance offered and the Supported Improvement Plan agreed.
• Any alternative considerations including redeployment to a lower graded post.

Occupational Health

At any point during the process where an employee discloses a health issue that may impact on their performance, the employee must be referred to the Occupational Health Department. Managers are advised to suspend the process whilst waiting for a response from Occupational Health, which should assist in determining the most appropriate way to move forward.

It would also be normal practice for any employee commencing long term sickness during the capability process to be referred to Occupational Health.  The Capability Process is likely to be adjourned during the absence and recommence when the employee resumes to their normal contractual hours.

Non-Engagement In the Process

The Capability Process should be a supportive two way process, aimed at supporting the employee to develop and improve to attain the required standards of performance.

However, if the employee is repeatedly unable or unwilling to attend meetings  then due consideration of all of the facts in relation to this matter should be considered.  These should include:-

–       Normal processes for failing to attend meetings.

–       The seriousness of the issue being considered.

–       The employee’s general work record, work experience, position and length of service.

–       Medical opinion on whether the employee is fit to attend.

On the basis of these considerations, it should be determined whether it is reasonable to proceed in the employee’s absence based on the information available.

Continued failure by the employee to accept the issues raised and to fully engage in the Capability process may also result in the matter being considered as a Conduct issue and progressed through the Disciplinary Policy and Procedure.

The Use of a Mentor

It can be beneficial to nominate a mentor to assist and support the employee throughout the Supported Improvement Plan.  It would be expected that the mentor will be a member of staff with significant experience and understanding of the areas of improvement identified in the Supported Improvement Plan.

The mentor should meet with the employee on a regular basis throughout the Supported Improvement Plan, at least on a weekly basis, during the period of supported improvement in order to discuss progress and provide any additional support.

These meetings should be open and honest discussions reviewing the employee’s progress and should be clearly documented in the log within the Supported Improvement Plan, including details of the employee’s progress, areas which continue to require improvement and any additional support or assistance offered.

These logs should be signed by both the mentor and the employee after each meeting.

Documentation & Record Keeping

It is imperative that all discussions in relation to performance issues are clearly documented, including initial discussions during the process of Supported Improvement, highlighting the areas of improvement and the support and assistance offered.

Clear and concise documentation is also an integral part of the informal and formal process and use of the standard documentation within this guidance should assist in ensuring that appropriate documentation is utilised.

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