Read Standard 1: leadership and staffing

Organisations have objectives and priorities that: 

• reflect their overall vision, values, strategy and aims 
• are driven by what is relevant and important to people who use the services they provide 
• are effectively communicated and well understood across the organisation and the community it serves 
• are reflected in the objectives of services, teams and staff job roles. 

Organisations ensure effective leadership and staffing governance through:  

• a clear and well-publicised management structure 
• defined roles and responsibilities for escalation and management of clinical risk (see Standard 4) 
• documented processes for direct reporting to the multi-disciplinary clinical leadership team 
• regular reporting in line with The Health and Care (Staffing) (Scotland) Act 2019 where appropriate. 

Each service has a staffing method agreed in partnership with the workforce, which: 

• emphasises values-based practice, including compassion and understanding⁷ 
• involves staff in decision making, where appropriate 
• promotes inclusivity, dignity and respect for all staff 
• enables continuous safe care and support to be provided  
• ensures workforce plans for future levels of staffing are safe and sustainable. 

Organisations implement the appropriate skills mix and numbers of suitably qualified and competent staff to ensure the: 

• health, wellbeing and safety of patients, staff and visitors 
• provision of safe and high-quality care. 

Organisations have an escalation process to identify and mitigate risks relating to: 

• staffing numbers and skills mix 
• succession planning 
• availability of senior clinical decision makers. 

Staff experience leadership at all levels that is values-based, person-centred and trauma-informed. 

Organisations ensure systems and processes are in place to address fairly any workplace issues in a timely manner. 

Staff work within defined clinical and professional competencies and: 

• understand their responsibilities and respect the professional competencies and contributions of all members of the care team 
• seek specialist advice, second opinion or further clarification where needed. 

Organisations check and validate the professional qualifications and registration (where applicable) of staff: 

• prior to their starting employment 
• throughout the duration of their employment. 

Staff are supported to meet the revalidation requirements set by their respective professional regulator, including collecting and submitting evidence.

Organisations demonstrate implementation of Disclosure (Scotland) Act (2020) and have robust processes in place to identify and mitigate the risk of employing staff who have criminal convictions for, or previous upheld or current ongoing investigations into, abuse, harm or unsafe practice. 

Organisations have robust process in place for the recruitment (including background and safeguarding checks), deployment and supervision of volunteers as well as staff. This includes access to compassionate and inclusive leadership, appropriate training and support and role descriptions. 

What does the standard mean for people?

• You can be confident that the organisation is well led and managed.  
• Staff will have time and support from their teams to care for you.
• You will be supported by staff who are confident in their organisation and leadership.  
• You can be confident that staff are appropriately and safely recruited.

What does the standard mean for staff?

Staff, in line with roles, responsibilities and workplace setting:

• experience values-based, person-centred and trauma-informed leadership 
• understand and act in line with core values 
• understand their role within a multi-disciplinary team 
• are supported and feel valued and enabled 
• work in appropriately staffed teams and services. 

What does the standard mean for the organisation?

Organisations, in line with their respective governance and delivery structures: 

• provide clear leadership and oversight of healthcare services  
• ensure appropriate and sustainable levels of staffing and skills mix to ensure continuity of care and support in line with The Health and Care (Staffing) (Scotland) Act 2019 (see also Standard 5) 
• have workforce resilience plans and implementation monitoring 
• support staff through effective, values-based, person-centred and trauma-informed leadership 
• have a clearly communicated vision that is in line with national priorities. 

Benchmarking and measuring performance: Examples of what meeting this standard might look like [linked criteria]

Examples may vary according to the size and scale of the service, NHS board, organisation. 

• Documented organisational priorities and objectives, for example strategy documents or annual reports. [1.1] 
• Board reports on adherence to provisions of The Health and Care (Staffing) (Scotland) Act 2019. [1.2] 
• Workforce resilience plans, such as mutual staffing cover arrangements between small organisations or practices. [1.3 – 1.5] 
• Use of staffing tools and workload models to plan required capacity. [1.3 – 1.5] 
• Audit of staff vacancies, succession planning, staff retention and safe staffing levels and action plans. [1.3 – 1.5] 
• Processes for escalating and mitigating staffing risk with contracting NHS boards. [1.5] 
• Evidence of leadership training and development pathways and frameworks.10, 14 [1.6] 
• Evidence of staff feedback and experience of leadership, such as iMatter. [1.6] 
• Clear organisational charts describing lines of accountability and defined roles and responsibilities, accountability and funding structure for multiagency teams and services. [1.2 – 1.8] 
• Audit of response to workplace issues. [1.7] 
• Enhanced background checks for staff and compliance with professional regulators. [1.9 – 1.11] 
• Policies for volunteer recruitment, training and management. [1.12]