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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Staff Appraisal Policy

1. Purpose

The purpose of this policy is to establish a clear, consistent and effective process for the appraisal of people working at {{org_field_name}} and to ensure compliance with the requirements relating to staff support and development within the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

In particular, Regulation 36 requires the service provider to have arrangements for the support and development of staff and to ensure that people working at the service receive appropriate supervision and appraisal, induction, core training, specialist training where appropriate, and support to undertake further training relevant to their role.

In accordance with the statutory guidance issued under the Regulation and Inspection of Social Care (Wales) Act 2016 and used by Care Inspectorate Wales (CIW) when assessing compliance, all staff will have an annual appraisal which provides feedback on their performance and identifies areas for training, learning and development in order to support them in their role.

The appraisal process supports reflective practice, professional competence, continuous learning and accountability. It provides a formal opportunity to review performance, recognise achievements, consider feedback, identify learning and development needs, agree objectives and determine any support required to enable the person to carry out their role safely and effectively.

Appraisals will also support compliance with the current Social Care Wales Code of Professional Practice for Social Care Workers and the Code of Professional Practice for Social Care Employers, together with any other professional code applicable to the person’s role. Where a person is registered with a professional regulator, the appraisal process will support them to maintain the knowledge, skills, competence and professional development required for their registration.

The overarching purpose of appraisal is to ensure that people working at {{org_field_name}} remain appropriately supported, competent and accountable and are able to contribute to the provision of safe, person-centred, rights-based and high-quality care and support which promotes the well-being and personal outcomes of individuals using the service.

2. Scope

This policy applies to all staff employed by {{org_field_name}}, including full-time, part-time, temporary, bank and other workers, and applies to all roles within the care home, including care and support workers, registered nurses, team leaders, kitchen and domestic staff, activities staff, administrative staff and members of the management team.

All directly employed staff will receive a formal appraisal at least annually.

In accordance with Regulation 36 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, appropriate support, supervision and appraisal arrangements must also be in place for other people working at the service, including volunteers.

Where agency workers or other externally supplied workers are used, {{org_field_name}} will ensure that appropriate arrangements exist for monitoring and reviewing their performance, competence, conduct and suitability while working at the service. Where the individual’s formal employment appraisal is undertaken by an external agency or employer, {{org_field_name}} will provide relevant performance information to that organisation where appropriate and will obtain sufficient assurance that concerns, identified learning needs and performance issues are addressed. The use of an external employer or agency does not remove {{org_field_name}}’s responsibility to ensure that people working at the service are suitably competent, supported and safe to undertake their role.

Formal annual appraisal is separate from routine supervision. Staff will continue to receive one-to-one supervision in accordance with the organisation’s Staff Supervision, Training and Development Policy and the requirements of the statutory guidance. The annual appraisal will take account of relevant information arising from supervision throughout the appraisal period.

A six-monthly appraisal review or follow-up may also be undertaken to monitor progress against agreed objectives, development plans or identified performance requirements. Additional reviews may be undertaken where there is a significant change in role, responsibilities, performance, competence or development needs.

3. Related Policies

This policy should be read alongside the following:

• CHW27 – Staff Supervision, Training, and Development Policy
• CHW28 – Staff Conduct and Code of Ethics Policy
• CHW04 – Good Governance Policy
• CHW30 – Equality, Diversity, and Inclusion Policy
• CHW31 – Disciplinary and Grievance Policy
• CHW07 – Person-Centred Care Policy

Relevant legislation, statutory guidance and professional standards

This policy will be implemented in accordance with:

• Regulation and Inspection of Social Care (Wales) Act 2016;
• Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, particularly Regulations 34, 36, 37 and 38;
• Welsh Government statutory guidance for service providers and responsible individuals on meeting the service standard regulations for care home services, as amended;
• the current Care Inspectorate Wales inspection framework applicable to care home services;
• the current Social Care Wales Code of Professional Practice for Social Care Workers;
• the current Social Care Wales Code of Professional Practice for Social Care Employers;
• applicable Social Care Wales practice guidance;
• where applicable, the relevant professional code and registration requirements of another professional regulator, including the Nursing and Midwifery Council; and
• Equality Act 2010, UK General Data Protection Regulation and Data Protection Act 2018.

4. Policy Statement and Implementation

4.1 Purpose of Staff Appraisals

The staff appraisal process at {{org_field_name}} is designed to:

• provide meaningful feedback about the staff member’s performance;
• recognise achievements, strengths and positive practice;
• identify areas in which performance, knowledge, skills or competence require development;
• review the staff member’s ability to fulfil the responsibilities and accountabilities of their role;
• review compliance with relevant legislation, organisational policies and procedures, professional standards and codes of practice;
• review training, learning and continuing professional development completed during the appraisal period;
• identify outstanding, refresher, specialist or additional training and development needs;
• consider relevant feedback about the staff member’s performance, including feedback from individuals using the service where appropriate;
• consider whether the staff member continues to demonstrate the knowledge, skills, competence, conduct and values necessary for their role;
• support reflective practice and learning from experience, incidents, complaints, safeguarding matters, feedback and other relevant information;
• agree clear objectives and actions for the next appraisal period;
• identify any support, supervision, training, reasonable adjustment or other resource required to enable the staff member to fulfil their role effectively;
• support staff who are professionally registered to maintain the requirements of their registration and relevant professional code; and
• promote safe, person-centred, rights-based and high-quality care and support.

For social care workers, appraisal discussions will take account of the current Social Care Wales Code of Professional Practice for Social Care Workers and relevant practice guidance. Managers and leaders will additionally be expected to demonstrate the leadership responsibilities applicable to them under the Code.

4.2 Frequency and Structure

All directly employed staff will receive a formal appraisal at least once in every 12-month period. This reflects the statutory guidance relating to Regulation 36 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, which requires all staff to have an annual appraisal providing feedback on their performance and identifying areas for training and development.

Appraisal does not replace regular supervision. Staff will continue to receive one-to-one supervision in accordance with {{org_field_name}}’s Staff Supervision, Training and Development Policy. Information arising from supervision will inform the annual appraisal where relevant.

A six-monthly review of the appraisal objectives will normally be undertaken by {{org_field_name}} to monitor progress. Additional appraisal or performance review meetings may be undertaken where required because of:

• a significant change in role or responsibilities;
• identified training or development needs;
• concerns regarding performance, competence or conduct;
• a return to work where a review of competence or support is required;
• significant changes to legislation, regulation, guidance or professional standards;
• changes in the needs of individuals using the service which require additional knowledge or competence; or
• other circumstances where additional support or review is reasonably required.

Each formal appraisal will include the following stages:

1. Preparation and reflection – the staff member will be given an opportunity to reflect on their performance, achievements, learning, challenges and development needs before the appraisal.
2. Evidence review – the appraiser will consider relevant information available from the appraisal period. This may include supervision records, training and competency records, agreed objectives, feedback, compliments and complaints, incidents, safeguarding learning, audits and other relevant evidence of practice.
3. Appraisal meeting – a formal, private discussion will be held between the staff member and an appropriate manager or senior member of staff.
4. Performance and professional development review – the meeting will consider the staff member’s performance, competence, training, professional development and ability to meet the responsibilities and accountabilities of their role.
5. Objectives and action planning – clear objectives, development actions, support requirements, responsible persons and review timescales will be agreed and recorded.
6. Follow-up – progress against agreed actions will be monitored through supervision and, where applicable, the six-monthly review.

4.3 Performance Areas Reviewed

The appraisal will provide a structured assessment of the staff member’s performance, competence, learning and development during the appraisal period. The areas considered will be proportionate to the person’s role and responsibilities and will include, where relevant:

• performance against the requirements of the person’s job description and agreed objectives;
• the quality, safety and consistency of their practice;
• contribution to the achievement of individuals’ personal outcomes;
• delivery of person-centred and rights-based care and support;
• respect for individuals’ dignity, privacy, wishes, preferences, culture, identity and communication needs;
• adherence to legislation, regulations, organisational policies and procedures;
• compliance with the current Social Care Wales Code of Professional Practice for Social Care Workers and relevant practice guidance;
• where applicable, compliance with another professional code, registration requirements and standards of practice;
• competence in carrying out the duties and responsibilities of the role;
• communication and professional relationships with individuals using the service, relatives, representatives, colleagues and other professionals;
• relevant feedback about the staff member’s performance, including feedback from individuals using the service and, where appropriate, their representatives or carers;
• learning arising from compliments, complaints, incidents, safeguarding matters, errors, near misses, audits or other quality assurance activity where relevant to the person’s role;
• attendance, punctuality and reliability where these have a legitimate bearing on the staff member’s performance;
• completion of required induction, core training, refresher training, specialist training and continuing professional development;
• identified gaps in knowledge, skills or competence;
• maintenance of any required Social Care Wales or other professional registration;
• progress against objectives and development actions agreed at the previous appraisal;
• the staff member’s health, safety and well-being at work and any appropriate support or reasonable adjustments required;
• opportunities for further learning, professional development and career development; and
• objectives and development priorities for the next appraisal period.

Feedback used within the appraisal process must be relevant, appropriate and handled fairly. Where information identifies a concern about a staff member’s conduct, competence, safeguarding practice or fitness to practise which requires immediate action, the matter must not be delayed until the annual appraisal. It must be addressed promptly through the appropriate supervision, safeguarding, disciplinary, capability, fitness to practise or other organisational procedure.

The outcome of the appraisal, including agreed objectives, identified learning and development needs, required support and review dates, will be clearly documented.

4.4 Supporting Continuous Improvement

The appraisal process forms part of {{org_field_name}}’s arrangements for supporting and developing its workforce in accordance with Regulation 36 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

Training, learning and development needs identified through appraisal will be recorded, allocated appropriate actions and monitored through supervision, training records and subsequent review. Where the appraisal identifies that additional knowledge, skills, competence or professional development are required for the person to undertake their role safely and effectively, appropriate support and learning will be arranged.

Where recurring or service-wide learning and development needs are identified through appraisals, these will inform the service’s training needs analysis and workforce development planning. The service provider will undertake an annual training needs analysis, or more frequently where required, to ensure staff have the relevant skills and competence to meet the needs of individuals in accordance with the service’s Statement of Purpose.

Where an appraisal identifies concerns regarding a person’s performance or competence, appropriate action will be taken without delay. Depending upon the circumstances, this may include:

• additional supervision;
• coaching, mentoring or observation of practice;
• additional or refresher training;
• competency assessment;
• a structured performance improvement or support plan;
• adjustment of duties where necessary to protect individuals;
• use of the capability or disciplinary procedure;
• safeguarding action; or
• referral to Social Care Wales, the Nursing and Midwifery Council, the Disclosure and Barring Service or another relevant regulatory or professional body where the applicable legal or professional threshold for referral is met.

Appraisal will not be used as a substitute for taking immediate action where there are concerns about an individual’s safety, staff conduct, competence or fitness to practise.

Aggregated and anonymised workforce themes arising from appraisal, supervision, training and competency monitoring may be used as part of the service provider’s wider monitoring, workforce planning and quality improvement arrangements. Relevant themes may also be made available to the Responsible Individual to support oversight of the effectiveness, quality and safety of the service.

The Responsible Individual’s statutory quality of care review is undertaken separately in accordance with Regulation 80 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended. The quality of care and support must be reviewed as often as required and at least every six months, with the Responsible Individual preparing a report to the service provider which includes an assessment of the standard of care and support and recommendations for improvement.

4.5 Promoting Equality, Fairness, and Inclusion

All staff are treated fairly and equally throughout the appraisal process. Appraisers are trained to ensure appraisals are free from bias, discrimination, or assumptions. Staff may request the presence of a colleague or advocate during the meeting if they wish.

Adjustments are made where required for staff with disabilities, neurodiverse needs, or those for whom English is not a first language. The policy is in line with the Equality Act 2010 and the Human Rights principles as promoted by CIW​.

4.6 Confidentiality and Record Keeping

Appraisal records contain personal information and will be processed lawfully, fairly, securely and confidentially in accordance with the UK General Data Protection Regulation, the Data Protection Act 2018 and {{org_field_name}}’s Confidentiality and Data Protection Policy (CHW34).

Completed appraisal records will be retained securely within the staff member’s personnel or HR record in accordance with the organisation’s records retention arrangements.

Access to appraisal information will be restricted to persons who have a legitimate organisational or legal need to access the information. This may include the staff member, their appraiser, the Registered Manager, authorised HR personnel and, where necessary for the discharge of statutory oversight responsibilities, the Responsible Individual. Information will only be shared to the extent necessary and lawful for the purpose concerned.

The staff member will be given the opportunity to read the completed appraisal record and add comments before the appraisal is finalised. The staff member and appraiser should sign or otherwise formally acknowledge the record. A refusal by the staff member to sign does not invalidate the appraisal; the appraiser will record the refusal and, where provided, the reason.

The appraisal record will clearly identify:

• the date of the appraisal;
• the persons participating;
• performance and development matters discussed;
• relevant feedback considered;
• strengths and achievements identified;
• training, learning and development requirements;
• any identified competency or performance concerns;
• agreed objectives and actions;
• the person responsible for each action;
• required completion or review dates; and
• the date on which progress will next be reviewed.

Where an appraisal identifies information which must be reported or acted upon under safeguarding, whistleblowing, professional regulation, fitness to practise or other legal requirements, confidentiality will not prevent {{org_field_name}} from making the necessary disclosure or taking the required action.

4.7 Responsibilities and Oversight

The service provider has overall responsibility for ensuring that arrangements for the support and development of people working at the service comply with the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

The Registered Manager {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}} is responsible for the day-to-day implementation of the appraisal arrangements within the service. This includes:

• maintaining an appraisal schedule which enables all directly employed staff to receive a formal appraisal at least annually;
• ensuring appraisals are undertaken by persons with appropriate authority, knowledge and competence;
• ensuring appraisal discussions are meaningful and reflect the staff member’s role, responsibilities, performance and development needs;
• monitoring the quality and completion of appraisal records;
• ensuring relevant information arising from supervision, training, feedback, competency assessments and performance monitoring is appropriately considered;
• ensuring identified learning and development actions are recorded, allocated and followed up;
• ensuring performance, competence, conduct, safeguarding or fitness to practise concerns identified through appraisal are addressed promptly through the appropriate procedure and are not left until a subsequent appraisal;
• monitoring themes arising from appraisal in order to inform workforce development and training needs analysis; and
• ensuring appraisal records are available to CIW where lawfully required for regulatory inspection or assurance purposes.

The Responsible Individual will maintain appropriate oversight of the effectiveness of the service’s workforce arrangements as part of their statutory responsibilities for overseeing the management, quality, safety and compliance of the service.

A sample of appraisal records will be audited periodically to provide assurance that annual appraisals are taking place, are meaningful, identify appropriate development requirements and result in agreed actions being followed through.

5. Policy Review

This policy will be reviewed at least annually and earlier where necessary to ensure that it remains consistent with applicable legislation, regulations, statutory guidance, Care Inspectorate Wales requirements, Social Care Wales Codes of Professional Practice and practice guidance, relevant professional regulatory requirements and organisational practice.

An earlier review will be undertaken where there is:

• a change to relevant legislation or regulations;
• revised Welsh Government statutory guidance;
• revised Care Inspectorate Wales requirements or inspection methodology relevant to staff support and development;
• a change to a Social Care Wales Code of Professional Practice or associated practice guidance;
• relevant learning from an inspection, audit, complaint, safeguarding matter or regulatory action; or
• evidence that this policy is no longer operating effectively.

Where amendments are made, the revised policy will be communicated to relevant staff and managers and any consequential changes required to appraisal documentation or practice will be implemented.

The next scheduled review date will be 12 months from the date of the most recent formal review unless an earlier review is required.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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