/Policies and guidelines/Appraisal policy and guidance

Appraisal policy and guidance

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Policy owner: People consultant
Corporate lead: Director of people
Date approved by Joint Negotiating Consultative Forum(JNCF): April 2022
Date ratified by Trust Leadership team: April 2022
Date issued: July 2025
Next review date: June 2029

Executive summary

This policy sets out Leeds Community Healthcare (LCH) NHS Trust’s Appraisal process for staff on Agenda for Change terms and conditions. It localises the NHS Constitution through the trust’s vision, values and strategic objectives which is underpinned by the trust’s behaviours, known as How We Work (HWW).

This policy highlights the need for staff to perform the duties of their role (what they do) and the behaviours expected to be demonstrated while undertaking the role (how they do it). The appraisal process contributes to the Trust’s approach when managing concerns with performance.

The trust supports the philosophy that lifelong learning and development are key to delivering the NHS vision of patient centred care. As such the trust is committed to equipping staff with the necessary skills required to undertake their roles competently and confidently and the appraisal policy and process supports this.

This appraisal policy and process is supported by appraisal documentation (see My LCH for all appraisal documentation) and should be read in conjunction with the:

Managing concerns with performance policy

This policy has been developed in consultation with staff side and management side representatives, and other key stakeholders.

This policy may be reviewed at the request of management or staff side by giving 4 weeks’ notice with reasons for the review.

Equality analysis

Leeds Community Healthcare NHS Trust’s vision is to provide the best possible care to every community. In support of the vision, with due regard to the Equality Act 2010 General Duty aims, Equality Analysis has been undertaken on this policy and any outcomes have been considered in the development of this policy.

1. Introduction

The trust has 3 key values that underpin and represents the way in which the Trust works. The trust values are:

We are open and honest and do what we say we will.
We treat everyone as an individual.
We are continuously listening, learning, and improving.

These values localise the NHS Constitution and provide the guiding principles that underpin everything the trust does.

This policy supports the Trust’s vision, values, and strategic objectives to provide the best possible care to our patients by recruiting, retaining, and developing the best possible staff.

Staff will demonstrate their performance by meeting the requirements of their role and by displaying the appropriate behaviours to support our values.

The appraisal process is the cornerstone to achieving our vision, values and strategic objectives through our key asset, our staff.

2. Aims and objectives

Appraisal and associated process (outlined in section 8) is a key determinant of organisational success and effectiveness and is the backbone to engaging with our staff. It gives the opportunity to share what the trust is working towards and how the member of staff can contribute to this. It enables a conversation to take place around sharing achievements, establishing expectations, supporting development, and providing feedback.

The appraisal process is about motivating and developing our staff and supporting them in performing their roles at the highest standard to deliver the best possible care to our patients.

The appraisal process contributes to the trust’s approach to managing concerns with performance at the earliest stages.

3. Definitions

All staff referenced in this policy relates to staff employed by the trust under the Agenda for Change terms and conditions. Medical and dental staff are covered within the appraisal policy and guidance for consultants, SAS doctors, and dentists.

The appraisal process refers to the continuous professional development of an individual through induction, 3-month objective setting meeting, 1 to 1s, 6-month (mid-year) review and annual appraisal.

4. Responsibilities

All staff employed by Leeds Community Healthcare NHS Trust must work in concordance with the Leeds Safeguarding Multi-Agency policies and procedures and local guidelines in relation to any safeguarding concerns they have for service users and the public with whom they are in contact.

Chief executive and trust board are responsible for:

ensuring that the appraisal policy and procedure are in place and that all staff employed under the Agenda for Change terms and conditions are aware of, comply with and operate within the policy
the performance management of this policy.

Executive directors and senior Management team are responsible for:

ensure this Policy is implemented within their sphere of responsibility
monitor the compliance target with the policy through the business committee
manage non-compliance with this policy through the business committee reports (general managers and business unit clinical leads)
proactively manage areas of concern highlighted with general manager and clinical leads
support and prioritise methods of development and training needs identified through this process

The business committee will:

review monthly reports from the workforce director on key performance indicators (KPI’s) and seek assurances about appraisal process
where issues are identified, advise, recommend, and monitor improvements.

Director of workforce is responsible for:

on behalf of the chief executive, ensuring the implementation of this policy throughout the trust and evaluate its effectiveness
informing the relevant Workforce teams of any issues which may change the needs of the Policy, Toolkit, or training provision
oversight of training needs emerging from appraisal process
providing assurance regarding the quality of appraisals.

Managers or appraisers are responsible for:

ensuring that each individual member of staff has meetings planned in throughout the year in line with procedure
ensure new members of staff have an objective setting meeting within their first 3 months of joining the trust which should be recorded on ESR
undertake relevant training to support the delivery of quality 1 to 1s, 6-month (mid-year) reviews and annual appraisals
ensuring each member of staff is clear on the expectations around the tasks, competences and duties of the role and expected behaviours in line with HWW
sharing with each appraisee the expectations around completing the preparation form
preparing for the appraisal meeting using the guidance set out on My LCH and if appropriate other feedback tools, for example, peer review
ensuring that each individual member of staff has regular feedback on their performance and ensure feedback mechanisms within the team exist
supporting employees to understand the links between trust and departmental goals and targets in relation to individual performance
supporting and encouraging the development of clinical and patient management skills appropriate to the role and in line with professional and trust requirements and codes of conduct
ensuring that each individual member of staff’s communication and access requirements are met (for example, interpreter, hearing loop, accessible venue)
encouraging and facilitating access to training and development opportunities, for example, time away from service, knowledge of long course process
ensuring 3-month objective setting meetings and annual appraisal meetings are accurately recorded on ESR
ensure the appraisal paperwork is saved in a locally agreed location, only accessible to those who need it

Employees have a responsibility to:

attend and participate in the planned meetings, 3-month objective setting, one to one’s, 6 month (mid-year review) and annual appraisal
make their line manager aware of any access requirements they have (for example, interpreter, hearing loop)
prepare for the appraisal using the guidance provided on My LCH ensuring examples of practice are captured
understand their own role and how it links with trust, departmental and team goals and targets
recognise and take opportunities for self-development, actively seeking feedback from others and using feedback to improve performance
reflect on learning experiences to allow knowledge and skills to be applied in the workplace
strive to Complete the objectives and priorities set or provide mitigation for those not completed
be open and transparent in identifying their development needs

Workforce information and organisational development (OD) teams will:

work with services to support them attaining appraisal compliance
provide training and guidance to support those who undertake appraisals
ensure all training has clear aims, objectives and delivery methods which may include the provision of alternative delivery format to meet the needs of individuals, for example, providing signers or audio versions at training sessions
report monthly as part of the integrated performance report to the business committee on appraisal compliance
advertise appraisal training provision
identify and monitor appraisal compliance and take appropriate action.

5. Performance of the task

All staff will be appraised on their fulfilment of the competencies and duties for the role they are undertaking and achievement of the agreed objectives for the year being reviewed. The process will start at the induction stage for new members of staff with an objective setting meeting for the year ahead. This should be carried out in the first 3months and recorded on ESR. A full appraisal process will ensure that this objective setting meeting is followed by regular one to one meeting, a 6-month (mid-year) review and an annual appraisal. See section 8 for the process.

5.1 Assessing the task

Managers and appraisers who work directly with individuals can assess performance through observation and supervision processes and are therefore able to determine whether someone is performing as expected against their competencies, duties and agreed objectives. Other methods of assessment include peer review, shadowing practice, patient feedback, review of care records, reports the individual may have written, or information available from electronic systems such as SystmOne or Datix. 360° feedback is also a tool that staff and managers/appraisers find useful to get a wide-ranging viewpoint from others who work with the member of staff. These assessments should however be managed appropriately where there has been training in their use and how to give feedback. Please speak to the ODI team to access these tools.

6. Performance of behaviours

The trust behaviours, How We Work (HWW), support the appraiser and individual to provide examples of how the behaviours are demonstrated or not and how they support the trust’s values.

These values localise the NHS Constitution and provide the guiding principles that underpin everything the trust does. What we say, how we say it and how we interact with others is just as important as what we do. Staff with a professional registration must adhere to their professional code of conduct and professional registration policy which includes the revalidation process.

6.1 Assessing behaviour

Staff are expected to always behave professionally showing dignity and respect to others that they work with and to service users and members of the public. If the expected behaviour outlined in HWW is not demonstrated, it is the responsibility of all staff to raise the concern directly with the individual or with the appraiser or manager. If we do not challenge
inappropriate behaviour this will be seen as accepting the behaviour and, in some cases, becomes the ‘norm’. Inappropriate behaviour must be discussed when it occurs to give the individual opportunity to acknowledge, reflect and improve. If after informal discussions the behaviour has not improved, it is at the managers/appraiser’s discretion to determine when to escalate to the bullying and harassment policy.

7. Training needs

All staff who undertake appraisals are expected to undertake relevant training (either through their line manager or more formal training) to support the delivery of quality appraisal conversations. Line managers should also refer to the online Appraisal Hub available on MyLCH.

8. Process for undertaking appraisals

To establish the process of support and review at the beginning provides a good foundation to build the employment relationship. Teams within the Trust that have built this foundation can demonstrate how this has a positive impact on retention of staff and lower sickness rates. Indicated below are the stages of the process that are mandatory and best practice. The appraisal checklist forms part of the appraisal toolkit available on My LCH.

Induction and initial objective setting

For individuals new in role, the appraisal process should begin as part of the induction arrangements. This part of the process is the ‘initial objective setting meeting’ which outlines the objectives and expectations around task and behaviour (HWW) for the forthcoming year, how their role fits with the competencies and duties, team, service, trust and appropriate
learning and development identified. The “settling in conversation” template (found on My LCH) can be used in part to help with planning and discussion. This part of the process is crucial in the support and development of our staff. This initial meeting should be carried out within the first 3-months and recorded in ESR by the line manager on ESR.

One to one meeting

It is good practice to hold one to one meeting on a regular basis with members of staff, giving them the opportunity to discuss their work. These are supportive meetings to ensure that staffs needs are being met; objectives set are being progressed; and HWW is being demonstrated. If there are any issues that have been identified in the individual’s work or
development the one-to-one meetings are a good time to address these, they should not be left until the appraisal meeting.

The appraiser and (or) manager should document these discussions; this could be in the form of an email outlining the points discussed. This can be placed on file to inform future discussions.

6 month meeting (mid-year review)

This mid-year review should be used to ensure staff are progressing their objectives and HWW is being demonstrated. The annual appraisal paperwork can be used to provide more structure to this meeting ensuring that the core elements within the form are covered.

The appraiser and manager should document these discussions, this could be in the form of an email outlining the points discussed. This could be placed on file to inform further discussions.

There is no need to record this meeting on ESR.

Annual appraisal

This meeting involves both the appraiser and member of staff and dedicated time must be set aside for this. The meeting should be held at a mutually convenient time that allows both parties sufficient time to prepare beforehand using the appraisal preparation form.

The appraisee should complete the relevant sections of the paperwork and send to their appraiser at least 1 week before the meeting.

The appraisal should take place in a venue that is private and avoids distractions or interruptions.

At the meeting the core elements of appraisal will be discussed which will include confirmation of expectations around performance and standards of behaviour.

The appraisal meeting brings together all the discussions that have taken place throughout the year and jointly reflected on in a structured way. The appraiser and member of staff will look back and reflect on achievements, challenges, objectives, standards of performance, behaviour, and personal development plan for the review period. The guiding principle of the annual appraisal is “no surprises”.

The main purpose of the appraisal meeting is to look at the way in which an individual member of staff is performing and developing in relation to:

the duties and responsibilities of their post and current agreed objectives
the application of knowledge and skills within the workplace
the appropriate behaviour and attitude expected within the workplace
the consequent development needs of the individual member of staff
future career development
the support required so they can stay well and be their best at work.

The meeting will consider how the member of staff is performing against the objectives and expectations. This could include reviewing a particular piece of work, peer review or perhaps elements of the individual’s personal development portfolio that they are prepared to share.

The appraiser should:

encourage the member of staff to take ownership of their appraisal meeting and come prepared (it may be useful to have a brief pre meet several weeks in advance of the appraisal)
review the paperwork to understand what elements are important for the individual and prepare appropriately
identify what support is needed for the individual to reach their potential
offer examples of what the individual has done well and if necessary, examples of things that have not gone so well
discuss any challenges the individual/team or service has experienced over the review period and the impact of these on the individual
provide developmental feedback in a way that focuses on what the individual has done or not done
evaluate training and development activity that has taken place and its application in the workplace
encourage members of staff to be involved in the formulation of objectives or standards at both departmental and individual levels, making sure that there are links to the trust’s overall corporate aims and objectives
identify and agree a personal development plan with learning goals that are realistic for the individual and for the organisation
ensure that objectives are aligned with team, service, and organisation goals
explain how they will support the member of staff’s learning and development
ensure there is an accurate record of the discussion.

The appraiser should:

raise any issues or concerns with the individual as they occur, with discussions taking place on an ongoing basis (one to one meetings). There should be no surprises in the annual appraisal meeting
encourage the individual to do most of the talking, the conversation should be 80/20
use a coaching approach to empower the individual to own their objectives, standards, behaviours and learning and development needs or solutions.

This meeting should be recorded in ESR (guidance can be found on MyLCH via the Appraisal Hub).

*Please note that for recording purposes only, the following review types will be included as indicating that an appraisal has taken place: review, medical appraisal, AfC development review, and performance appraisal.

8.1 Priorities and objectives

It is important for staff to understand what is expected of them and the value of their contribution. Understanding the priorities and objectives for the trust, service and team will help them to see how their individual contribution adds value.

Having a written record of the priorities and objectives for each individual member of staff provides clarity and structure. These can be reviewed at different points in the appraisal process to ensure things are on track and can highlight any support the individual may need in completing these. Being clear on what it is that needs to be achieved and when it needs completing helps the individual to focus on the purpose and outcome, enabling the appraiser to hold the member of staff to account for what has been previously agreed.

8.2 Documentation

The appraiser and member of staff should prepare for the meeting by using the employee led appraisal paperwork completed by the appraisee before the meeting takes place. This approach focuses on the core elements of the appraisal discussion, particularly what matters to the individual.

The summary of the meeting should be recorded in the green section of the paperwork. This should provide an accurate record of the meeting however there is an opportunity for the member of staff to suggest amendments to this once it is completed.

The appraisal paperwork should be kept on file for reference by the appraiser and a copy for the member of staff. The documentation is a confidential record however access to this may be required for business continuity and quality assurance purposes.

Notes taken within one-to-one meetings and any other discussions relating to the individual’s performance should also be kept.

8.3 Development plan

The development plan supports the individual to achieve their objectives and undertake their role. Development will be considered at the time of preparation for both appraiser and member of staff. Any development needs identified will be discussed, considered and where possible agreement reached at the time of the appraisal meeting. The development needs
should be captured in the preparation form. When considering what development needs are required, the appraiser and member of staff should:

clearly focus on the knowledge, skills, and competence that the individual needs for the post
identify the learning and development that the individual needs to enable them to develop and apply their knowledge and skills in the shorter and longer term
prioritise the learning and development that needs to take place, considering:
- The specific requirements that affect the work of the individual (for example, statutory, and regulatory requirements)
- Organisational direction, policy and other factors that may affect priorities
- Any specific objectives that the individual needs to meet in their post
- The individual’s strengths and development areas.
identify how the individual prefers to learn (for example, group work, practical on the job learning, formal courses, shadowing) and plan accordingly
identify who has responsibility for taking the different aspects of the learning and development forward, along with a means for reviewing that this is happening as planned

As job roles and team, departmental and trust procedures change and develop, staff will also need to develop new skills and knowledge. Individuals should be encouraged to take the initiative, informing their own development plan with the help of their appraiser. It should be remembered that learning and development can take place through many different means and will not always be a ‘course’ or ‘training’. For example, it may be through reading, shadowing, buddy arrangements or mentoring, experiential (for example, exposure to a situation with support).

Appraisers will provide commitment to the support of individuals throughout the appraisal process and in meeting learning and development needs however individuals are also responsible for informing, being aware of their development needs and participating in the development opportunities offered.

8.3.1 Access to development

The trust will expect that staff applying for any development will be up to date with the statutory and mandatory training relevant for their role. Development will not be authorised until the necessary statutory and mandatory training is completed. For more information refer to the trust’s personal and professional development policy.

9. Poor or unsatisfactory performance

LCH will aim to ensure all staff clearly understand the standards of performance expected of them and are fully supported to achieve and maintain these to a high standard.

If it becomes apparent that an individual is not achieving the required level of performance, managers should refer to the Managing Concerns with Performance Policy and deal with the situation in a prompt, constructive and effective manner.

Unsatisfactory performance is defined as “where a member of staff is failing, in a significant or persistent way, to carry out their responsibilities or duties in a satisfactory manner, either due to lack of skills, knowledge, attitude or some other reason.”

If at any point within the appraisal process the line manager and appraiser feels the individual is not making progress towards achieving objectives this should be picked up in line with the managing concerns with performance policy.

10. Raising concerns

If the member of staff is unhappy with the appraisal discussion or outcome or the appraisal is not being offered or regularly postponed, both parties should seek to resolve this informally.

If the informal mechanism is unable to resolve the differences, guidance should be sought from HR.

11. Monitoring compliance and effectiveness

Minimum requirement to be monitored and audited	Process for monitoring and audit	Lead for the monitoring and audit process	Frequency of monitoring and auditing	Lead for reviewing results	Lead for developing and reviewing action plan	Lead for monitoring action plan
Annual appraisal activity captured	Appraisal data	Appraiser and people operations manager	Once appraisal taken place and monthly	Appraiser and people operations manager	Appraiser and people operations manager	Appraiser, people operations manager and assistant director of people operations
Effectiveness of appraisal process	Staff survey	Senior people consultant	Annually	Senior people consultant	Senior people consultant	Senior people consultant and assistant director of people operations

12. Approval and ratification process

The policy has been approved by the Joint Negotiating Consultation Forum (JNCF) and ratified by the remuneration committee on behalf of the board.

13. Dissemination and implementation

This policy will be available to staff via the intranet and referenced through training.

Implementation will require:

operational directors, heads of service and general managers to ensure staff have access to this policy and understand their responsibilities for implementing it into practice
the OD lead will provide appropriate support and advice to staff on the implementation of this policy.

14. Review arrangements

This policy will be reviewed by the author three years following ratification or sooner if there is a local or national requirement.

15. References

Managing concerns with performance policy
Bullying and harassment policy
Agenda for Change terms and conditions of service handbook
NHS Constitution
Professional registration policy
Personal and professional development policy