CORPORATE & LOCAL INDUCTION POLICY

Transcription

1 Wirral University Teaching Hospital NHS Foundation Trust Policy Reference: 123 CORPORATE & LOCAL INDUCTION POLICY Version: 7 Name and designation of policy author(s) Mrs A Callcott, Service Delivery and Compliance Manager, HR & OD Mrs S Green, Director of HR and Organisational Development (HR & OD) Approved by (committee/ group Workforce & Communication Programme Board name) Date approved 6 th January 2012 Date ratified by HMB 13 th January 2012 Date policy published 7 th February 2012 Review date 13 th January 2015 Target audience Links to other strategies, policies, procedures All Staff Safe Employment; Mandatory Risk Management Training, Learning and Development and other associated Risk Management and Trust Wide Policies

2 CONTENTS Content Page 1 Introduction Purpose Scope Definitions Duties / Responsibilities Individual Roles Chief Executive Director of Human Resources & Organisational Development Corporate Directors/Divisional Heads HR & OD Department Managers Staff Professional Lead Trainers (PLT s) Committee Roles Hospital Management Board Workforce and Communications Programme Board Delivery of Induction Components of Induction Corporate Induction Programme Initial Mandatory Training Programme Local and Basic Induction Requirements Booking and Compliance Records Management Exceptions Compliance Reporting Attendance and Compliance Management References...8 Appendices Appendix 1 Corporate Induction Minimum Content...9 Appendix 2 Local Induction Checklist...10 Appendix 3 Basic Induction Record Card...13 Appendix 4 Request for Exceptions Approval...15

3 1 Introduction Wirral University Teaching Hospital NHS Foundation Trust (the Trust) recognises the importance of an effective induction for all new employees into the Trust. A structured induction programme consisting of both Corporate and Local induction elements ensures that new employees receive the essential information they require to enable them to operate effectively as quickly as possible and in doing so ensures their safety, the safety of patients and minimises the risk to the organisation. 2 Purpose The purpose of this Policy is to set out the minimum standards required for the delivery of Corporate and Local Induction to ensure that the Trust meets its statutory and regulatory requirements and is assured that staff are equipped to provide safe care within a safe environment. It defines the way in which areas of responsibility for induction within the Trust have been determined, together with the primary method for delivery and monitoring. The policy for Corporate and Local Induction is based upon the following key principles: a) Corporate and Local Induction is an essential component of the Trust s governance framework and risk management strategy and meets the requirements of NHSLA Standards and Care Quality Commission Standards; b) Corporate Induction is recorded within the Electronic Staff Record (ESR) (via the Oracle Learner Management System (OLM)) and Local Induction is linked to the annual individual review/appraisal and personal development planning process within the organisation; c) New permanent employees and temporary employees contracted for a period greater than 8 weeks receive a planned and professional welcome to the Trust; d) New employees are integrated into the organisation as quickly as possible, providing new employees with the practical information they need to begin their new role; e) Essential safety and risk management information is imparted to minimise risks to themselves, the patients and the organisation; f) The new employee is introduced to Trust policies and procedures which govern and regulate the work that they do; g) New employees understand the vision and goals of the Trust and thus the context in which they are working and their role in supporting the achievement of Trust goals and business plans; h) New employees are supported in their new post, helping them maximise their potential as quickly and efficiently as possible. Wirral University Teaching Hospital NHS Foundation Trust Page 1 of 15

4 3 Scope This policy applies to all staff directly employed by and working within the Trust on a permanent, fixed term, rotational or temporary contract of greater than 8 weeks duration (including bank staff). Temporary staff engaged for shorter periods must receive a basic induction /appropriate workplace orientation and risk management training to fulfil their temporary duties. 4 Definitions Induction: The formal entry into an organisation, position or office. Corporate Induction: The half-day programme, designed as an introduction to the organisation. Initial Mandatory Training: Training that staff are required to attend upon appointment or by exception within the first 3 months of employment. The subjects required on initial appointment, together with the process for monitoring and managing non-compliance are identified in the Prospectus which can be found on the education and training section of the intranet. Local Induction: variable in length and method of delivery, supported by the line Manager, this induction will be aligned to specific role and area of work. The minimum requirement for local induction is contained within the local induction checklist (Appendix 2) Workplace Orientation: Informing and showing a member of staff the working environment, domestic arrangements, essential health and safety information. All Staff : For the purposes of this policy all staff includes all individuals directly employed by and working within the Trust on a permanent, fixed term, rotational or temporary contract of greater than 8 weeks duration. Temporary Staff: For the purposes of this policy temporary staff includes all individuals employed directly or indirectly (including agency) for a period of less than 8 weeks in duration. Personal Portfolio: A Personal Portfolio is a document that is used by individual members of staff to record their performance and for planning and recording their development. It is a document that enables staff to collect evidence that demonstrates the knowledge and skills they have gained within their role. The main focus of the document is to support Individual Review Process/Appraisal linked to the NHS Knowledge & Skills Framework (KSF) and Core Competencies for Medical Staff. Induction Booklet : provided to new staff on the corporate induction programme which includes supplementary information and guidance including a list of Trust Policies. Wirral University Teaching Hospital NHS Foundation Trust Page 2 of 15

5 5 Duties / Responsibilities 5.1 Individual Roles Chief Executive The Chief Executive is ultimately accountable to the Board for the Trust s compliance with Statute and Regulation Director of Human Resources & Organisational Development The Director of HR & Organisational Development is responsible for ensuring that there is a Corporate Induction Programme and that minimum requirements for Local Induction are set out within policy. This includes ensuring that there are resources for booking, recording attendance and completion of local induction, basic induction and for monitoring compliance with and the effectiveness of this policy; the escalation of non-compliance through the Trust s governance and performance management structures; and for ensuring that the quality of the programme is reviewed and continuously improved Corporate Directors/Divisional Heads Corporate Directors/Divisional Heads or equivalent are responsible for ensuring that all staff and temporary staff working within their Division/Departments comply with this policy. Those Divisions providing specialist training or support for Corporate or Local Induction and Initial Mandatory Training are responsible for providing adequate resources to meet the demand and for ensuring that, where necessary, record keeping is integrated into the Oracle Learning Management System (OLM) to enable accurate monitoring of compliance HR & OD Department The HR & OD Department will manage booking and attendance for Corporate Induction and Initial Mandatory Training following receipt of the request to appoint paperwork from a line manager. The department through the shared service is responsible for checking completion of local and basic induction requirements, recording completion of local induction for all staff and basic induction for temporary staff, and production of Quarterly Performance Alert Reports Managers Managers (medical and non-medical) are accountable for ensuring that all staff and temporary staff comply with this Policy. Managers are also accountable for undertaking Individual Review/Appraisal, for ensuring that induction (corporate, local and basic) is undertaken and provided, where appropriate competence/understanding is assessed (for detail please refer to the Individual Review & Payband Gateway Management Policy, and equivalent policies for senior medical staff and doctors in training). Where it is demonstrated through reporting that there is non-compliance, the individual s manager will take appropriate action to ensure the staff member attends/undertakes the required programme. Compliance with this policy will be included within the Individual Review/Appraisal for all staff with line management responsibility. Wirral University Teaching Hospital NHS Foundation Trust Page 3 of 15

6 5.1.6 Staff All staff must attend the Corporate Induction Programme and Initial Mandatory Training along with local induction requirements. Staff must be aware of these requirements and are responsible for ensuring, with their manager, that they attend or undertake the appropriate training/sessions within the timescales set on the programme Professional Lead Trainers (PLT s) The Trust has identified leads against subject areas / disciplines for in house training. The PLT s for each subject / discipline are responsible for the delivery and evaluation for their training sessions. They are also responsible for the continual review and update of training sessions to ensure integrity of the sessions. 5.2 Committee Roles Hospital Management Board The Hospital Management Board (HMB) is responsible for the performance management of the Trust and as such the management of non-compliance and consideration of business cases or action plans in pursuance with this Policy. The HMB approves any amendments to the Policy and delegates responsibility for receiving, reviewing and acting upon the Quarterly Performance Reports to the Workforce and Communications Programme Board. HMB receives reports / minutes from the Workforce and Communications Programme Board Workforce and Communications Programme Board Workforce and Communications Programme Board (WCPB) is responsible for the performance management of this Policy. It receives reviews and acts upon the Quarterly Performance Reports. 6 Delivery of Induction 6.1 Components of Induction The Induction Programme consists of three key elements: The Corporate Induction Programme Initial Mandatory Training Programme Local Induction The first two components of the programme are organised to be delivered on a block basis to enable managers to plan training before the new member of staff commences in the workplace and be assured they have received an introduction to the organisation and completed the necessary mandatory risk management training. The content of this programme is subject to amendment in response to service needs / risk; however its primary aim is to incorporate those subjects requiring attendance of the majority of staff. The block organisation of the programme, encourages concentrated attendance, minimising alterations to planned rotas and reduces the impact upon the services provided by the Trust. 6.2 Corporate Induction Programme New staff will normally be required to attend the Corporate Induction Programme on the first day of their employment. In exceptional circumstances, staff may attend at a later date as long as it is within the first 3 months of employment, subject to approval Wirral University Teaching Hospital NHS Foundation Trust Page 4 of 15

7 of the application for exception being made to the HR & OD Department in advance of the date of commencement. See Section 7.2 for details. The Corporate Induction Programme has been designed to reflect the needs of the new employee and Trust requirements. The programme is a half-day, usually provided on alternate Monday mornings. The programme is available on the HR/OD section of the Intranet. The minimum content is described in Appendix 1. A Trust representative who is competent in the topic being presented delivers the Corporate Induction Programme. Quality assurance is undertaken by the HR & OD Department for all sessions. The HR& OD Department is responsible for undertaking an annual review of the Corporate Induction Programme to ensure the programme is reviewed, evaluated and appropriate to the needs of the Trust, Managers and the inductees in line with national guidance. 6.3 Initial Mandatory Training Programme All new staff, within the scope of this Policy, are required to attend or undertake the Initial Mandatory Training Programme. The date of attendance/completion then determines the End Date for Compliance (EDC) for the first refresher Mandatory Risk Management Training required. For details of requirements for each staff group please refer to the Mandatory Risk Management Training Policy and prospectus which can be found on the education and training section of the intranet. 6.4 Local and Basic Induction Requirements Upon completion of initial mandatory training, all staff will report to their workplace where they will begin their Local Induction. There is core content that will be applicable to all individuals and specific components that will be staff group/role specific or unique to the individual workplace and the individual s role within it. The core content applicable to all staff is described in the Local Induction Checklist attached at Appendix 2. This checklist should be completed by the member of staff in conjunction with their line manager. The line manager must sign the local induction off as complete. A copy of the completed form should be retained in their personal portfolio. This checklist includes a section for additional information related to the requirements of the role or area. Managers should keep a copy of the checklist ensuring it is available for audit purposes. The Individual Review/Appraisal should include a review of understanding and application of the information/knowledge gained as part of the Local Induction and any action required built into the Personal Development Plan arising from this review. For temporary staff employed for a period of less than 8 weeks, a Basic Induction /workplace orientation is required. The minimum content is described in the Basic Induction Record Card a copy of which is attached at Appendix 3. This will need to be submitted to Staffing Solutions within the HR & Well Being Business Services at Countess of Chester Hospital with the first payment request/timesheet for the individual. Wirral University Teaching Hospital NHS Foundation Trust Page 5 of 15

8 7 Booking and Compliance 7.1 Records Management Attendance at Corporate Induction and Initial Mandatory Training for all staff groups will be recorded using the Electronic Staff Record (ESR) and the Oracle Learner Management System (OLM). The HR & OD department will manage booking and attendance recording for the Corporate Induction and Initial Mandatory Training Programmes for all staff and will book a place on the first available induction date upon receiving a request to appoint a new member of staff from the line manager. An offer letter is sent to the successful candidate from HR & Well Being Business Services confirming the appointment and date to attend Corporate Induction. A follow up letter with the Corporate Induction programme enclosed is sent at a later date from the Induction Co-ordinator. Divisions and Corporate Departments will be charged for staff non-attendance on the Corporate Induction Programme and/or the Initial Mandatory Training Programmes, in accordance with the Trust s Learning and Development Policy, with the exception of Flexibank Staff. In the event that an individual fails to attend, this is identified on the sign in sheet and the Induction Co-ordinator informs the HR & Well Being Business Services, who will follow up non-attendance. Attendance information for Corporate Induction is alerted to line managers through the DNA (did not attend) process. Initial Mandatory Training for all staff is incorporated into the Quarterly Mandatory Risk Management and Individual Review Performance and Alert Reports. This must be used by line managers to follow up non attendance the HR & OD Department to assess action required based upon capacity and demand for the following quarter managers to take action to ensure that all staff comply with this Policy. Line managers are responsible for recording completion of the core and specific Local Induction requirements by completing the local induction checklist during their induction period. An initial Individual review should be completed at the end of the first 3 months for new staff and that the completion date is notified to the HROD Department for compliance reporting via the electronic notification form which can be found in the 10 Most Useful section on the homepage of the intranet by clicking on KSF and Individual review, then click on the IR notification box. The HR & OD Department through the HR & Well Being Business Services will contact all new starters who have a permanent post 3 months after commencement of employment to confirm that the Local Induction has been undertaken. This will be recorded on the compliance tracker in the HR & Well Being Business Services. For temporary staff, a Basic Induction Record Card (Appendix 3) will need to be signed by the manager and submitted to Staffing Solutions department within HR & Well Being Business Services at Countess of Chester Hospital with the first payment request/timesheet for the individual. Wirral University Teaching Hospital NHS Foundation Trust Page 6 of 15

9 Performance against both of these compliance processes for local induction will be reported by Division as part of the Quarterly Performance and Alert Report to the WCPB and in the event of non compliance, HR & Well Being Business Services will alert line managers who are expected to follow up non completion. 7.2 Exceptions All newly appointed staff to the Trust is required to comply with the Trust s Safe Employment Policy, and to have attended the Trust Corporate Induction programme, following which they will undertake the initial mandatory training required for their post, prior to commencing in the role. In cases where line managers have been unable to secure a place on the Corporate Induction or Initial Mandatory Training Programme prior to the new employees proposed start date, and, where delay in appointment would cause operational difficulties, the line manager must submit an Exceptions Request to the HR & Well Being Business Services using the pro forma attached at Appendix 4, if they wish the member of staff to commence prior to Corporate Induction taking place. This requires the line manager to submit a written statement undertaking that the necessary risk management procedures will be put in place and that the individual concerned will be appropriately supervised. All staff who are subject to an Exception must complete the Corporate Induction and Initial Mandatory Training within the first 3 months of employment within the role. 7.3 Compliance Reporting Compliance against the Policy will be monitored using non-compliance as the denominator. It is recognised that there will be a level of non-compliance with initial mandatory training and local induction, which is acceptable (e.g. sickness absence). This level will be determined on an annual basis, informed by risk levels, absence levels and improvement objectives. This may be applied universally or by subject or staff group and will be subject to approval by the Workforce and Communications Programme Board. Non Compliance will be reported as follows: Workforce and Communications Programme Board Quarterly Performance Report; Divisional Management Boards Quarterly Performance and Alert Report; Line Managers non compliance alert for corporate and local induction via the DNA process and quarterly performance and alert report for Initial mandatory training. 7.4 Attendance and Compliance Management It is the Manager s responsibility to ensure attendance at or completion of all aspects of induction. Completion of Local Induction is required as part of the Knowledge and Skills Framework (KSF) for non-medical staff and as part the portfolio assessment for medical staff. It is essential that managers responsible for Individual Review/Appraisal are conversant with the up to date requirements for the member of staff to be reviewed/appraised. Wirral University Teaching Hospital NHS Foundation Trust Page 7 of 15

10 In order to provide a control and assurance mechanism, the HR & Organisational Development Department, using the Electronic Staff Record (ESR), informed by the Oracle Learning Management System (OLM) tracks attendance/compliance with Corporate Induction. HR/OD is responsible for producing Performance and Alert Reports in accordance with Section 7.3 and will assist in the management of bookings and breaches wherever possible, either by managing bookings or by realigning/increasing capacity. Managers receive notification of non-attendance (DNA), together with the appropriate charge as detailed in section 7.1 of this policy. It is the responsibility of line managers to manage non-attendance using the appropriate performance management policy or procedure. In addition to non-attendance confirmation, managers receive non compliance alert for corporate and local induction and performance and alert report for Initial mandatory training, which should be used to facilitate planning of attendance and to validate the records. As detailed in Section 7.1, the HR & OD Department will contact all new staff following 3 months in employment to confirm that the Local Induction has been undertaken. For temporary staff, a Basic Induction Record Card must have been submitted with the first payment request/timesheet for the individual. Performance against both of these compliance processes will be reported as part of the Quarterly Performance and Alert Report to the Workforce and Communications Programme Board. Divisional Management Boards (DMB) receive Quarterly Performance and Alert Reports highlighting current non compliance levels for Corporate Induction and DNA rate for the division. The also receive non compliance for mandatory risk management training inclusive of initial mandatory training and potential non compliance during the next quarter. DMBs are expected to discuss, agree and minute actions where compliance is not achieved at DMB meetings. 8 References NHSLA Risk Management Standards Care Quality Commission Standards Trust Policy 124 Mandatory Training Policy Trust Policy 136 Safe Employment Policy Trust Policy 180 Learning and Development Policy Wirral University Teaching Hospital NHS Foundation Trust Page 8 of 15

11 Appendix 1 Corporate Induction Programme Minimum Content Who we are o Foundation Trust Information o Location of Trust Services The Structure of the Organisation o Structure of the Organisation o Board of Directors o Vision and Goals Funding of Services o Commissioning o Activity Information Corporate Values o Executive Welcome o Core Values o Key Challenges and Achievements Individual Development o Service Improvement Goals and Individual objectives o Knowledge and Skills Framework/Competency Frameworks o Individual Review/Appraisal Excellent Employer o Our commitment to you o What is expected of you Next Steps for your first 3 months Wirral University Teaching Hospital NHS Foundation Trust Page 9 of 15

12 Appendix 2 Name of Staff Member Line Manager Post Title / Grade Division Directorate/Department Date of Appointment Start Date if Different Date attended Corporate Induction Date attended Initial Mandatory Training Line Managers Signature: Staff Members Signature: Date completed: Local Induction Minimum Content Checklist This checklist is to ensure that all aspects of your local induction are covered in a timely and effective manner. As each item is discussed it will be signed off by the person providing the information, and by yourself, once you feel the information has been adequately covered. If any item does not apply to your post please mark N.A. If you feel that any area has been missed, and you require further information, please bring it to the attention of your line manager. The induction should be commenced on the first day in the workplace. Once the induction is complete, you and your line manager (or equivalent) should sign the checklist. The complete and signed checklist will be placed in your personal portfolio and your line manager will keep a record that corporate and local induction has been completed. You will be contacted by the HR & OD Department after 3 months in employment to verify that this has been completed. 1. ORIENTATION Signature of Line Manager Overview of Divisional/Department structure/governance arrangements Tour of Department and any relevant areas Cloakrooms, lockers, domestic and dining arrangements Safety Procedures, inc those covering: Fire Safety, Fire Points and emergency number and departmental Health, safety and security including departmental risk assessments including location of incident reporting forms Introduction to colleagues and key personnel Date Signature of Employee Date Wirral University Teaching Hospital NHS Foundation Trust Page 10 of 15

13 Sources of help and key contacts Mentor/Buddy /Supervisor arrangements (as appropriate) 2. DOCUMENTATION Signature of Line Manager Car Parking Permit application if not already obtained prior to commencement. Request for PCIS / access Emergency contact number 3. SYSTEMS Telephone and Bleeps PC / Telephone access and system Mail Filing and Administration 4. POLICIES Responsibilities in relation to policy awareness Other Key Policies e.g. those covering Resuscitation, Medicines management, Security, Incident reporting, Violence and Aggression, Human Resource, Waste management, No Smoking, Confidentiality, Medical devices, Infection Control, Hand Hygiene, Attendance and leave, Major Incident, Consent to Treatment including delegated consent where appropriate. Location and access to policies 5. OUR VALUES and BEHAVIOUR STANDARDS Core Values - PROUD Patients are at the heart of all we do Respect each other every day Our hospitals are your hospitals United to provide the best possible patient care Dedicated to excellence in all we do 6. COMMUNICATION and INFORMATION Information Governance Use of Trust intranet/ system Meetings / communications structure Internet, intranet and policy Newsletters TIE Brief 7. JOB ROLE / ROLE OF DEPARTMENT / TEAM Discussion of job role, expectations and Date Signature of Employee Date Wirral University Teaching Hospital NHS Foundation Trust Page 11 of 15

14 limitations. KSF Post outline (where applicable) /relevant competencies/objectives Department objectives Initial performance and development (appraisal ) review date planned Identification of immediate training and development needs Confirmation of essential clinical procedures Confirmation of diagnostic and therapeutic equipment to be used as part of role Professional conduct Hours of work / shift patterns / on call arrangements Familiarisation with equipment and procedures Clinical specific information 8. TRAINING Initial Mandatory training completed Please Refer to the Mandatory Risk Management Training Prospectus and Essential Training Matrix Additional mandatory training booked as relevant to role Please Refer to the Mandatory Risk Management Training Prospectus and essential training matrix 9. OTHER Discussion related to specific work area/activities not covered above Wirral University Teaching Hospital NHS Foundation Trust Page 12 of 15

15 Appendix 3 Name of Temporary or Agency Staff Member Line Manager Post Title / Grade Division Directorate/Department Date and Duration of Appointment Line Managers Signature: Staff Members Signature: *Date completed: Basic Induction Record Card Minimum Content The purpose of this Basic Induction Record Card is to ensure that any individuals employed directly with the Trust for a period of less than 8 weeks, or indirectly via an Agency receive essential workplace orientation including appropriate health and safety information, essential clinical procedures information and information to assist the individual in understanding and following the Risk Management Procedures of the Trust. If any item does not apply to the role that you are undertaking please mark N.A. If you feel that any area has been missed, and you require further information, please bring it to the attention of your line manager. The induction should be commenced on the first day in the workplace. Once the induction is complete, you and your line manager (or equivalent) should sign the checklist. *The complete and signed checklist must be provided with the first request for payment/timesheet and failure to do so may result in you not receiving your salary/payment. Minimum content Overview of the Department Tour of Department and any relevant areas Security pass, key, name badge and access codes Car parking, catering and washroom facilities Hours of work and shift patterns where applicable Procedures for reporting sickness etc. Fire Safety Procedures and Assembly points: Fire exits Equipment Signature of Line Manager Date Signature of Employee Date Wirral University Teaching Hospital NHS Foundation Trust Page 13 of 15

16 Alarms Evacuation procedures Moving & Handling Procedures: Equipment Procedures Resuscitation Procedures: Equipment Procedures Crash trolley location Medicines Safety Procedures: Procedures Relevant Risk Assessments Medicines common to the area Competency/policy for IV medicines administration Incident Reporting Procedures: Location and process for complete of Incident Forms Infection Control Procedures: Hand Hygiene procedures and equipment Infection status of clinical setting Health and Safety Procedures: Security Waste disposal Display Screen or other relevant regulations applicable within the area of work Wirral University Teaching Hospital NHS Foundation Trust Page 14 of 15

17 Appendix 4 REQUEST FOR EXCEPTIONS APPROVAL DIVISION: LOCATION: APPOINTING MANAGER: CONTACT NO. POST: BAND: HRS: NAME OF PERSON TO BE APPOINTED: PROPOSED DATE OF COMMENCEMENT: DATE APPLICATION SUBMITTED TO CRB: DATE BOOOKED ONTO CORPORATE INDUCTION: DATE BOOKED ONTO INITIAL MANDATORY TRAINING: STATEMENT (This should highlight any operational issues and a written undertaking as outlined in the Policy) Signature of Appointing Manager: Date of Request: Please forward to : HR & Well Being Business Services Moston Lodge Countess of Chester Hospital NHS Foundation Trust Liverpool Road Chester CH2 1UL Wirral University Teaching Hospital NHS Foundation Trust Page 15 of 15

18 Consultation, Communication and Implementation Consultation Required Authorised By Date Authorised Comments Equality Analysis Cathy McKeown 27 th November Screened for relevance full impact 2011 assessment not required. Policy Group Sue Green Director of HR/OD 11 th Nov 2008 Other Stakeholders / Groups Consulted as Part of Development Trust Staff Consultation via Intranet Checked for workforce / development, medicines, finance, NHSLA standards or wider corporate implications. HR Policy Development Group (20/12/11) Sample of operational managers across Trust including ward / department managers 11 th Nov th Nov 2008 Date notice posted in the Team Monthly Brief (TMB) February 2012 Date notice posted on the intranet January 2012 Describe the Implementation Plan for the Policy / Procedure (Considerations include; launch event, awareness sessions, communication / training via DMBs and other management structures, etc) Relevant guidance and/or training for appropriate staff within the HR & Organisational Development Department to enable them to fully implement this policy. Communication of responsibilities to relevant managers/committees via Divisional Management Boards Establishment of processes to underpin compliance and quality review By Whom will this be Delivered? HR & OD to lead the communication of the Policy Divisional and line managers responsible for ensuring that all existing staff are aware of the revised Policy Version History Date Ver Author Name and Designation Summary of Main Changes Dec Mrs Angela Calcott, Service Delivery and Revised Programme and Compliance Monitoring Compliance Manager following audit and action plan May Mrs Angela Calcott, Service Delivery and Updated to reflect new KPI template no change in Compliance Manager practice Dec Jill O Callaghan ESC Service Manager Updated to detail process no change in practice Mar Jill O Callaghan ESC Service Manager Updated to reflect the revised Trust governance structure May Jill O Callaghan ESC Service Manager Updated to detail process no change in practice Nov Cathy McKeown Principal OD Manager Updated to reflect Programme Board title. Minor amendments for clarity. Amendments to reflect HR shared services. Inclusion of role of lead trainers, for clarification Addition of core values in local induction checklist No change in practice Jan Jill O Callaghan ESC Service Manager Amendment made to clarify current compliance reporting (section 7.3)

19 Monitoring Compliance with the Policy Describe Key Performance Indicators (KPIs) Target How will the KPI be Monitored? Which Committee will Frequency Lead Monitor this KPI? of Review Compliance with Corporate Induction Requirements within first 3 months of employment for permanent staff. 100% Performance Report WCPB Quarterly Director of HR/OD DNA rate at Corporate Induction for permanent staff <5% Performance Report WCPB Quarterly Director of HR/OD Permanent staff who fail to attend corporate induction are followed up Non compliance against local induction requirements (permanent and temporary staff) 100% Quarterly Alert Reports WCPB Quarterly Director of HR/OD <5% Performance Report WCPB Quarterly Director of HR/OD All staff (permanent and temporary) who do not have a 100% Quarterly Alert Reports WCPB Quarterly Director of HR/OD local induction are followed up Non compliance with Individual Review Requirement <15% Performance Report WCPB Quarterly Director of HR/OD Compliance with process for checking that all new staff complete corporate and local induction, and with process for following up those who fail to complete corporate or local induction, as set out in this policy 100% Audit Report WCPB Annual Director of HR/OD Performance Management of the Policy Who is Responsible for Producing Action Plans if KPIs are Not Met? Which Committee Will Monitor These Action Plans? Frequency of Review (To be agreed by Committee) Workforce and Communications Programme Board Director of HR & Organisational Development for Corporate Actions Clinical Head of Division/Associate Director of Operations or equivalent for Divisional Actions Divisional Management Boards Divisional Quarterly Reviews Interim Workforce Committee Quarterly