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Education, Training and Development Mandatory Training

Tameside & Glossop Integrated Care NHS Foundation Trust EQUALITY IMPACT The Trust strives to ensure equality of opportunity for all both as a major employer and as a provider of health care. This policy has therefore been equality impact assessed by the Human Resources to ensure fairness and consistency for all those covered by it regardless of their individual differences, and the results are shown in Appendix 1.

Version: 1.0 Authorised by: Lucy Harmer Date Authorised: January 2017 Next Review Date: January 2020 Document Author: Lindsay Roodurmun

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Version Control Schedule Mandatory Training Version: 1.0

Version Issue Date Revision

0.1 June 2016 Reformatted; This version supersedes v2.8 of the Mandatory Training & Induction Training Policy September 2014

0.2 September 2016 Updates from HR management team Induction removed

0.3 September 2016 Updates from Policy Development group

0.4 September 2016 Updates from HR management team

1.0 November 2016 Final

1.0 January 2017 Approved

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TABLE OF CONTENTS

1. Introduction 4 2. Purpose 4 3 . Scope 4 4. Definitions page 5 5. Roles & Responsibilities 5 6. Policy Statement 6 7. Staff Training Records 7 8. Mandatory Training Matrix 8 9. Mandatory Training Updates 8 10. Essential Training 9 11. Identification of Training Needs 9 12. Failure to attend Mandatory Training 9 13. Pre-course work 10 14. Junior Doctors 10 15. Locum Doctors 11 16. Bank Staff 11 17. Policy Development & Consultation 11 18. Implementation 11 19. Monitoring 12

20. References 12

21. Review 13

22. Appendices 13

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1. Introduction 1.1 Under the Health & Safety Regulations, Employment Law and the Care Quality

Commission Tameside & Glossop Integrated Care NHS Foundation Trust is required to ensure all employees receive a formal, structured Induction, followed by regular mandatory updates.

1.2 Tameside & Glossop Integrated Care NHS Foundation Trust has set its compliance

target at 95% for all Mandatory Training. 2. Purpose 2.1 Tameside & Glossop Integrated Care NHS Foundation Trust is committed to

ensuring all employees attend the required Mandatory Training to ensure safe practice, thus minimising the risk of adverse incidents as a result of lack of knowledge or skills.

2.2 The purpose of this policy is to provide information to managers and staff of their

obligation to be compliant with their Mandatory Training as defined by the Trust. The policy ensures all managers and staff understand the difference between Mandatory Training, essential training and CPD (Continuous Professional Development) and it defines the structure for this training. This policy specifies what is mandatory for all employees as well as the learning programmes which will be defined by individual managers and their staff during the initial review and/or as part of the Appraisal process.

2.3 This policy outlines the roles and responsibilities of all employees of the trust, in

relation to Mandatory Training. The Policy will outline the way in which Mandatory Training is commissioned and the associated governance. The objective is to ensure Tameside & Glossop Integrated Care NHS Foundation Trust is a safe, quality and high performing organisation.

3. Scope 3.1 This policy applies to all permanent, temporary and Fixed - Term Contract staff

employed by Tameside & Glossop Integrated Care NHS Foundation Trust, including non-NHSP bank employees, agency locum staff (defined in this policy as “temporary”) that are not directly employed by the Trust.

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4. Definitions 4.1 Mandatory Training- Learning Activity required by statute, national or local policy,

to ensure the employee is able to work safely in their environment. The frequency of each mandatory topic will be defined as per the guidelines and this may differ per topic.

4.2 Essential Training- Learning activity that is essential to an individual, or a staff

group. This training will vary across the trust, and will be specific to the needs of that service/specialist requirements for that area, for example, NICE guidelines, etc.

4.3 CPD (Continuous Professional Development) – One, or a series of, learning and

development activities that may enhance an individual’s personal performance, or professional practice.

4.4 Induction- All new employees are required to complete an Induction programme

specific to their role. This will include a Corporate Induction, and a Local Induction. It may include other elements of Essential Training such as Care Certificate Training Programme or Patient Focused Programme.

4.5 Permanent Staff- All staff directly employed under a contract of employment with

the organisation and medical staff in training. Including fixed term contracts. 4.6 Temporary Staff- Workers, supplied by one organisation (agency staffing eg NHS

Professionals) for the use of another organisation. Temporary staff are the employees of the supply organisation.

4.7 Core Skills Framework- Nationally developed framework identifying statutory and

Mandatory Training for the NHS, including agreed aims, objectives and refresher periods.

4.8 ESR- Electronic Staff Record. The computer system which holds staff records,

including the OLM (Oracle Learning Management system) 5. Roles & Responsibilities 5.1 The Educational Governance Group: The purpose of the Educational

Governance Group is to provide leadership and direction for the Trust on all matters relating to education, training and development. In relation to Mandatory Training, this includes the agreement and ratification of all changes to Mandatory Training, namely, the Mandatory Training Matrix.

5.2 The Director of HR and Organisational Development: Executive responsibility for

the implementation and management of this Policy.

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5.3 The Assistant Director of Human Resources (Education, Training &

Development): Responsible for ensuring that this policy is implemented consistently across the Trust and overall responsibility for Mandatory Training compliance.

5.4 The Education Training & Development (ETD) Manager will have responsibility

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Monitoring compliance of the processes within the policy.

Supporting Managers and Heads of Service to meet Mandatory Training compliance.

Addressing non-compliance and non-attendance of Mandatory Training

Ensuring there is sufficient training capacity to maintain compliance across the trust.

Communicating and educating the trust in relation to the Mandatory Training Matrix, policy and associated processes and procedures.

5.5 The Education, Training & Development (ETD) Administration Department

have responsibility for:

The accurate and timely administration of all Mandatory Training including bookings, monitoring of attendance and associated course administration.

Recording of Mandatory Training through the production and inputting of class registers.

Booking all new employees onto mandatory classroom training. 5.6 Senior Managers: Senior Managers and Heads of Service are responsible for

the overall compliance of their department/division, which ensures safe working environments.

5.5.1 Line Managers: All Managers within the trust are responsible for:

Ensuring that all new members of their staff complete Mandatory Training within 3 months of joining the trust.

Monitoring attendance and completion of Mandatory Training for existing staff.

Contacting ETD at the earliest opportunity to notify of any situations involving non-attendance/non-completion or the risk of.

5.8 Members of Staff: Members of staff have a responsibility to ensure they are

qualified and safe to practice. They must take responsibility for attending all training and development booked by their line managers, or by themselves direct with ETD, and for identifying any training or development needs at any time including as part of their Annual Appraisal and on-to-ones with their manager.

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5.9 Workforce Information Team: Responsible for the production of monthly and ad hoc compliance monitoring reports. It is also the role of the Workforce Information Team to monitor the quality of data processed through the ESR system in line with their other duties.

6. Policy Statement 6.1 This policy defines the Mandatory Training requirements of all staff employed by

Tameside & Glossop Integrated Care NHS Foundation Trust, regardless of their role.

6.2 The trust has set a compliance target of 95% for all Mandatory Training. 6.3 The process of planning the Mandatory Training, communicating programme

information, managing nominations and recording and reporting attendance/non-attendance is described in this policy, as are the monitoring arrangements to ensure compliance, and the action to be taken where deficiencies are identified as a result of the monitoring.

6.4 The Core Skills Framework and associated workstream will ensure Mandatory

Training at Tameside NHS & Glossop Integrated Care NHS Foundation Trust is in line with national guidance.

7. Staff Training Records 7.1 The training records for Mandatory Training will be coordinated by the Education,

Training & Development team, and stored on ESR. 7.2 Staff transferring from other NHS trusts will have their Mandatory Training

assessed and transferred during the recruitment process; all new starters will be booked onto classroom Mandatory Training sessions prior to their start date as part of the new starter process. This includes the existing NHS staff who are booked onto any Mandatory Training they have expired in.

7.3 In order to complete Mandatory Training e-learning packages, new starters will be

provided with usernames and passwords by the ETD Administrators. 7.4 Members of staff booking on to training will hold a “Confirmed” status on the class

list, which will be updated to “Completed” once they have attended the training. 7.5 If members of staff do not attend (DNA), cancel or withdraw, their status will be

updated to reflect this. It will be the individual and the line manager’s responsibility to rebook the training if this occurs.

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7.6 DNA’s will be contacted following the start of the course, and will be asked to provide a reason for their failure to attend. DNA’s will be reported to the Trust on a monthly basis.

7.7 Staff Training Records will be updated on OLM by the ETD Admin team in a timely

manner following the start of the course. The training record is not accurate until the register has been updated, and the individual status on ESR has been changed from “Confirmed” to “Completed” (or appropriate status)

8. Mandatory Training Matrix

8.1 The Mandatory Training matrix will accurately reflect the topics that staff members

are required to complete, and will show the refresher periods that these topics will need to be repeated at to maintain compliance. Where there are different levels of training for different staff groups, this will be detailed within the matrix.

8.2 Tameside & Glossop Integrated Care NHS Foundation Trust will align the

Mandatory Training matrix with the Core Skills Framework and the Greater Manchester Mandatory Training naming conventions will apply.

8.3 The Mandatory Training matrix will be issued by the Education, Training &

Development manager and circulated to the trust via recognised communication methods.

8.4 The current Mandatory Training Matrix will be attached to this policy as Appendix 2. 8.5 Updates to the Mandatory Training Matrix will be ratified by the Educational

Governance group and the minutes are stored in a restricted access folder. 9. Mandatory Training Updates 9.1 The period that the Mandatory Training is valid for will depend on the topic and

level of that training; this may vary within a topic. This will be in line with the Core Skills Framework and may be defined by national guidelines, such as the Resus Council, or locally agreed by Educational Governance (where no guidance exists.) These details will be contained within the Mandatory Training matrix.

9.2 Line managers, locally based practice educators and individual members of staff

are encouraged to track when the Mandatory Training competency is due to expire so appropriate update training can be scheduled prior to the expiry date. This will also be indicated on the Mandatory Training report by turning Amber.

9.3 Priority booking on classroom training courses, where spaces may be limited, will

be given to those whose training has expired or are due to expire within the next 3

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months. On training where spaces are not limited, members of staff can attend outside of this window.

9.4 Members of staff attending classroom- based training are expected to comply with

the Trust Uniform Policy. 9.5 Monthly Mandatory Training reports will be circulated to divisions and the Trust

Board to show compliance against trust target. Monthly DNA reports will also be issued to highlight areas of low attendance.

9.5 Managers and staff will discuss Mandatory Training compliance during the annual

appraisal. 9.6 In line with Section 1(a) Pay Structure, Section 6(a) Career Progression and Annex

W: Pay Progression, of the Agenda for Change NHS Terms and Conditions of Service handbook, incremental pay progression at every incremental pay point for Agenda for Change employees is dependent upon achievement of performance and the demonstration of the right behaviours. This includes completion of all Mandatory Training. Failure to meet this requirement will mean incremental pay progression may be withheld. It is therefore crucial that all members of staff fully understand and correctly apply this policy.

10. Essential Training

10.1 Role specific training, that is not considered mandatory, will be arranged locally by

area leads, line managers and practice based educators. 11. Identification of Training Needs

11.1 Additional training and development that is identified via the appraisal process, or

as part of one-to-ones with line managers may be funded under the Training Funding Applications & Time off to Attend Training Policy. Please refer to this policy for further information of how funding for externally provided training may be sourced.

11.2 Additional CPD learning and development sessions may be delivered on an ad-hoc

basis and these will be communicated via recognised communication channels.

12. Failure to attend Mandatory Training 12.1 If a member of staff is unable to attend training, they must inform their line

manager, practice based educator and/or ETD Admin at the earliest convenience prior to the training starting.

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12.2 More than 48 hours before the training starts, this will be recorded as “withdrawn” and the individual will be expected to rebook at their earliest convenience. Within 48 hours of the training starting, this will be recorded as a DNA as it is unlikely that another member of staff could be released to fill this place at such short notice.

12.3 If a member of staff DNAs, the reason for this will be recorded in ESR. Line Managers will be contacted advising them of this occurrence. The monthly DNA report will provide managers with the information they need to address DNAs with their staff.

12.4 Members of staff that DNA more than 3 times in any 3 month period in a situation

where the service could release them to attend the course will be dealt with under the Conduct & Disciplinary Policy.

12.5 The trust understands that there may sometimes be extenuating circumstances

where it becomes difficult for a member of staff to attend pre-arranged training and this policy allows for emergency leave, parental leave, sickness, etc preventing individuals from attending training. The purpose of this clause is to address the high DNA rates across the trust and give clear expectations of what is required from members of staff and their managers in relation to Mandatory Training.

13. Pre-course work

13.1 Where a course requires pre-course work to be completed, staff must ensure that

this is completed within the required timescales.

13.2 The Education, Training & Development team reserve the right to turn staff away from a course if they have not completed the pre-course work to the required level, or to a satisfactory standard, or met a pass mark, where a pass mark exists.

14. Junior Doctors 14.1 Foundation Doctors are required to compete their Mandatory Training as part of

their training. This will be completed and recorded on the Horus e-portfolio, and monitored by the Medical Education Team.

14.2 All other junior doctors complete and/or upload their Mandatory Training through

the ROSTA/Core Skills training website and the information held on the ROSTA database is picked up and monitored by Medical Education. Any doctors who are not compliant are sent a reminder by Medical Education to update their Mandatory Training.

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14.3 Following completion of the F2 year, if a Junior Doctor becomes an employee of the trust, they complete/upload their mandatory training via the ROSTA/Core skills training website which is picked up in the same way as all other junior doctors.

15. Locum Doctors 15.1 Internal Bank Locum Doctors: It is the workers responsibility to ensure that they

are compliant with the Trust requirements for Mandatory Training. The Trust takes no liability where a doctor has failed to maintain compliance and an incident occurs. Where a doctor works over 51% of their total hours for Tameside Hospital, they can access Trust Mandatory Training packages. Where under 51% of total hours are worked for Tameside Hospital, the doctor will need to provide evidence of compliance of training undertaken elsewhere. (Taken from the Internal Bank Locum SOP)

15.2 Fixed Term Locum Doctors should provide evidence of their Mandatory Training

compliance. If the initial fixed term is longer than 3 months, the Locum Doctor can complete trust Mandatory Training. This applies either to the initial agreement term if longer than 3 months, or if the term extends past 3 months.

15.3 Agency Locum Doctors should provide evidence of their Mandatory Training

compliance. If the initial term is longer than 3 months, the Locum Doctor can complete trust Mandatory Training. This applies either to the initial agreement term if longer than 3 months, or if the term extends past 3 months.

16. Agency & Bank Staff 16.1 Mandatory Training for all other Agency staff will be organised through the Agency

that employs them.

16.2 Bank staff should work with their Bank to ensure they are up to date with their Mandatory Training. Those employed by Tameside & Glossop Integrated Care NHS Foundation Trust or another Greater Manchester NHS Trust will have their Mandatory Training stored in ESR under their Primary Assignment.

17. Policy Development & Consultation 17.1 This policy has been developed following a consultation with Staff Side, Senior

Managers & HR Professionals working within Tameside & Glossop Integrated Care NHS Foundation Trust.

18. Implementation 18.1 This policy is an update to the existing Mandatory Training policy. The Induction

element has been separated into a Trust Induction Policy.

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18.2 The most up to date Mandatory Training matrix will be communicated via

recognised staff communication channels, and a copy held on TIS for ease of access.

18.3 During the Corporate Induction introductory session, all new starters will be

advised of the requirements of this policy, and be given a copy of the most up to date Mandatory Training matrix.

19. Monitoring 19.1 Monthly Mandatory Training reports will be distributed to line managers and senior

managers to monitor compliance within their service area. New starters are excluded from this report for 3 months, and also those returning from long term sickness and maternity leave. Compliance will be reported at Trust Board, EMT, Educational Governance and Operations board with Divisional Managers.

19.2 Monthly DNA reports will be distributed to the Trust to allow line managers and

senior managers to monitor attendance, and triangulate this data with their Mandatory Training compliance.

19.3 Registers will be dip sampled on a monthly basis to ensure registers are inputted

accurately and in a timely manner. 20. References 20.1 Policies that relate to the Mandatory Training Policy include:

Training Funding Applications & Time Off to Attend Training policy

Appraisal Policy

Uniform Policy

Conduct & Disciplinary Policy

Incremental Progression Protocol

Internal Locum Bank SOP

20.2 External Links:

Core Skills Framework: http://tghwebapp/documents/CoreSkillsSubjectGuide.pdf

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21. Review 21.1 This policy will be reviewed every 3 years, or earlier depending on the results of

monitoring. 22. Appendices

Appendix 1- Equality Impact Assessment Appendix 2- Mandatory Training Matrix

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Analysis of Effects Assessment (AoE) Part 1: Initial screening template

Title of Policy /Procedure / Project / Strategy / Service to be assessed: Mandatory Training Policy

Short description of Policy / Procedure / Project / Strategy / Service (aims, objectives and purpose) Give a short description of the policy/proposal including its overall aims, objectives and purpose, including who it is going to impact upon eg: staff, public, patients, community, volunteers etc The purpose of the Mandatory Training Policy at Tameside & Glossop Integrated Care NHS Foundation Trust is to describe the principles and processes by which Mandatory Training is governed. The objective is to ensure staff and line managers are aware of their contractual obligation in relation to maintaining compliance with Mandatory Training and that Tameside & Glossop Integrated Care NHS Foundation Trust is a safe, quality and high performing organisation.

Date of assessment: September 2016

Person responsible for assessment: Lucy Harmer

Is this a proposed new policy/proposal? NO Is this a review of an existing policy/proposal? YES

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1. Who is responsible for the policy/proposal? (Consider the following; i. Who is accountable? ii. Who implements it? iii. Who is responsible for

policing/monitoring? iv. Who enforces the policy?)

All employees are responsible for adhering to the principles of this policy. Ultimately, the Trust Executive Team is accountable. The HR Department are responsible for the launch of the policy including Trust Wide communications. Line managers are required to enforce the policy and ensure the principles of the policy are adhered to within their areas of responsibility. Senior managers may nominate locally based educators, or suitably placed individual, to monitor and chase Mandatory Training compliance

2. Who are the main stakeholders in relation to the policy/proposal? (Consider the following; i. Who needs to be consulted /

informed about the policy/proposal?

ii. Who is the policy/proposal

intended to involve in the wider sense? For example; Staff/professionals, the public/community…

All employees of the Trust Line Managers Staff Side Representatives

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3. What outcomes are expected / desired from this policy/proposal? (Consider the following; i. Who will benefit from this

policy/proposal and in what way will they benefit?

ii. Does the policy/proposal

explicitly involve the elimination of inequality, or the promotion of equality?)

Staff will have a clear point of reference in terms of the trust’s commitment to Mandatory Training. Line Mangers will refer to this policy to reinforce to staff the obligation to remain compliant with Mandatory Training The policy promotes equality as all members of staff are equally responsible for becoming/remaining complaint regardless of role, band, etc. Support can be provided to those that require it so that each member of staff has the same opportunity to complete their Mandatory Training. This can be accessed through local managers, practice-based educators or the Education, Training & Development team.

4. The following section requires you to assess the likely negative impact and positive impact of your policy/proposal on

the nine Protected Characteristics as defined by the Equality ACT as follows. Please support any answers with evidence.

Guidance on what to include (These boxes can be expanded as necessary dependant on the amount of evidence available/provided)

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Protected Characteristics

Answers to: What likely adverse impact will this Policy / Service have on the public or staff, giving particular regard to potential impacts negative and positive in relation to:

Evidence: (What is your evidence for this answer? Consider; both quantitative and qualitative existing data.)

a. Race

None

All staff are required to complete Mandatory Training and maintain compliance.

b. Disability

None

All staff are required to complete Mandatory Training and maintain compliance. Primary delivery methods are established so that training can be accessed by that as required. Modes/methods of delivery can be adapted to meet individual needs by contacting the ET & D Manager. Details of e-learning support sessions should be communicated by managers to staff that require additional support.

c. Sex

None

All staff are required to complete Mandatory Training and maintain compliance.

d. Religion and

belief

None

All staff are required to complete Mandatory Training and maintain compliance.

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e. Sexual

orientation

None

All staff are required to complete Mandatory Training and maintain compliance.

f. Age

None

All staff are required to complete Mandatory Training and maintain compliance.

g. Carers

None

All staff are required to complete Mandatory Training and maintain compliance. Primary delivery methods are established so that training can be accessed by that as required. Modes/methods of delivery can be adapted to meet individual needs by contacting the ET & D Manager

h. Gender Reassignment

None

All staff are required to complete Mandatory Training and maintain compliance.

i. Marriage & Civil Partnership

None

All staff are required to complete Mandatory Training and maintain compliance.

j. Pregnancy & Maternity

None

All staff are required to complete Mandatory Training and maintain compliance. Primary delivery methods are established so that training can be accessed by that as required. Modes/methods of delivery can be adapted to meet individual needs by contacting the ET & D Manager Those returning form maternity leave will be removed from

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the Mandatory Training Report for 3 months to enable them to become compliant

K. Human Rights None

All staff are required to complete Mandatory Training and maintain compliance.

5. Is there any further evidence / data that you would consider relevant or necessary in order to answer the above question? If so, please detail. *

Those returning from maternity leave and long term sickness with have three months to return to compliance and will not be included in the report for this time. Information for staff with additional learning needs is available on TIS (Education & Training pages) Managers should make themselves aware of this information.

* If you require a significant amount of additional data, have identified a high and medium risk associated with the policy/service would you consider; i. adjusting the policy/proposal and completing the screening again?

or ii. automatically carrying out further investigation through an full impact assessment?

Why would you need to go straight to an AoE (part 2)

6. Are any of the above impacts

(detailed in 4a – K) justifiable, valid or legal? Please explain?

N/A

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7. Is this policy/proposal missing a

valid opportunity to promote equality of opportunity for one or more of the groups (see 4a) concerned? Please expand.

No

8. Does this policy/ proposal promote the Trusts Values and Behaviors (see below) for all of the protected characteristics:

Yes

8a. Respect: Does your policy promote treating everyone with dignity and respect at all times?

Yes- this is a clear policy for all members of staff, outlining what is expected and the way in which compliance should be monitored.

8b. Learning: Does your policy promote and encourage learning?

Yes- learning should be regularly refreshed to ensure safe practice.

8c. Care: Does your policy offer support and understanding and promote understanding of privacy and confidentiality?

Yes – those on maternity leave, or long term sickness are excluded from the report.

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8d. Communication: Does your policy encourage listening and welcome feedback (engagement)?

Yes- Heads of Service and line managers can communicate with the ETD team. All amendments to the matrix will be tabled at Educational Governance for discussion and approval.

8e. Safety: Does your policy outline responsibilities and improve quality for all.

Yes- the policy reinforces the statutory requirement for all staff to be compliant with Mandatory Training.

9. Based on the above, do you consider that this policy/proposal now requires a full impact assessment?

NO

If NO, no further assessment is required. Ensure that findings are published as ‘Part 1 Analysis of Effects’. If YES, complete question 9 and proceed to full impact assessment and action plan

10. Who will be responsible for carrying out the full Analysis of effects: part 2?

Signed (Responsible Manager for Policy/proposal)…Lindsay Roodurmun Date 26th October 2016 Countersigned………Lucy Harmer Date…………26th October 2016

Hyperlinks to: Analysis of Effects Assessment Guidelines