1. Board Assurance Framework 2012-2013

2. Strategic Objective: Working with strategic partners to provide high quality, cost effective services that are valued and recognised by patients, commissioners and the wider population ControlsGaps in ControlsMitigating ActionsPositive AssuranceGaps in Assurance Standing Financial Instructions (SFIs) in place. Budgets are closely monitored to prevent overspending. Cost control in place through budgetary management and training. Internal Audit annual plan in place. Contract meeting with PCT formalised to ensure control on PCT and LCH decision making. Board approved Quality Strategy in place, with quality impact assessments undertaken on CIPs, breakthrough aims identified and CQUIN targets in place. Long-term financial model developed and being utilised for business planning (LTFM). Draft IBP2 submitted to Board Feb 12. Board development plan for all aspects of Monitor assessment presented and support pack issued to all Board members – on- going. Key messages included in monthly Board reports. NHS contracts leaves risk of disinvestment with provider organisations. Cost Improvement Targets set by Division and process for identifying, recording and reporting to Divisions and Board re-launched March 12. Divisional workshops to reconfirm long term CIP targets and to encourage bottom up development of longer term CIP by service. Mar 12. Engagement with CCGs and Cluster commissioners to get formal sign up to LCH IBP and outline income profile. Demonstrate delivery performance of CIPs whilst improving quality – ongoing reporting to Divisions and Board. Service line reporting continues to be developed and presented to the Board on quarterly basis. Monthly financial performance reports to the Board demonstrating track record of delivering to budget. Monthly integrated performance and quality report to the Board. Finance and Commercial Committee in place, reporting directly to the Board on detailed financial performance. Board-agreed Long Term Financial Model that sets out financial challenge for LCH, with a downside scenario. Positive Assurance from MIAA audits on the budget setting and monitoring process reported to Audit Committee and (via Audit Committee minutes) to the Board. Annual external audit of accounts and annual report undertaken by Audit Commission, reported to the Audit Committee and (via minutes) to the Board. CIP plan to underpin 2011/12 financial performance reported to Board in October 2011 and submitted to the SHA. Commercial paper and dashboard routinely submitted to Finance & Commercial Committee Long-term assurance on the delivery of the cost improvement plans Detailed scrutiny of Quality Strategy to take place at Healthcare Governance Subcommittee. Strategic Risk: 1a - Failure to meet the scale of efficiency savings included in the contract value resulting in inadequate surplus to progress to Foundation Trust, or for reinvestment into services Date added CQC ref OwnersInitial risk (Likelihood x Consequence)Date reviewed Risk following review (LXC) Mar-11Reg 10 (Outcome 16) GMA/HL 15 (3x5) April 201215 (3x5)

3. Strategic Objective: Working with strategic partners to provide high quality, cost effective services that are valued and recognised by patients, commissioners and the wider population ControlsGaps in ControlsMitigating ActionsPositive AssuranceGaps in Assurance LCH have formalised contract negotiations and contract adjustments with LPCT LCH have resolved activity recording issues, recognised by LPCT and accepted that taking on additional activity from this baseline is an efficiency Block contract mechanism Quality KPIs to be developed to ensure that high standards of patient safety and effectiveness of care and good patient experience are maintained. (Aug 11) Completed and monitored via the performance report Deliver 2011/12 agreed Commissioning for Quality and Innovation (CQUIN) and all contractual key performance indicators (KPIs) (March 12) Engage with Commissioners to agree capacity & demand management model and development of balanced contractual mechanisms to maintain or improve quality. Negotiate fixed baseline with Commissioners.. Alignment of IBP with Commissioning intentions/Clinical Commissioning Group requirements to be undertaken at the Service Improvement Group. On-going - Specific meeting to discuss commissioning intentions with Clinical Commissioning Groups set up for Dec 2011. Outcome that commissioners recognise that they will need to invest in community services to continue out of hospital strategy. Still need to ensure that contract mechanism follows this intention. Specific meeting with commissioners to performance monitor quality measures and targets. Monthly performance report provided to the Board. External monitoring of CQUIN undertaken by Liverpool PCT and NHS Sefton and reported via Finance and Commercial Committee and (via minutes) to the Board. New performance framework developed and reported to the Board monthly Monthly contract compliance meetings with commissioner, which monitors contract performance as reported to the Board through the Integrated Performance and Quality Report. Strategic Risk: 1b - Commissioners' short-term approach to contracting and commissioning, focusing on financial efficiency and not acknowledging demand increases may lead to adverse effect on quality of services. Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar-11Reg 10 (Outcome 16) GMA/HL 12 (4x3)April 2012 12 (4x3)

4. Strategic Objective: Working with strategic partners to provide high quality, cost effective services that are valued and recognised by patients, commissioners and the wider population ControlsGaps in ControlsMitigating ActionsPositive AssuranceGaps in Assurance Regular compliance monitoring e.g. CQUIN, quality contract, CQC, Health Act at IQGC. Systems in place to monitor incidents, complaints and claims with directorate level reporting Clinical governance working groups in place in each directorate Risk register system in place in each directorate National Patient Safety Agency process for ranking and managing all incidents, complaints and risks. Improvements in operation of reporting process through the governance structure (upwards and downwards). Approved process for recording, investigating and reporting all incidents, complaints and risks to ensure that they are managed in a timely and appropriate manner and the Board are kept informed of the progress on high scoring incidents, complaints and risks (May 2011) Key performance indicators developed for each directorate as part of the business planning process Ongoing proactive work by the Counter Fraud Specialist to minimise risk of fraud. Maintain unconditional CQC registration and retain NHS Litigation Authority level 1. Progress plans to meet level 2 compliance. Review of governance/risk management agreements throughout organisation. Divisional business plans being developed for February 2012 submission – complete but on- going development of divisional business plans Involve infection control specialists in estates and facilities work streams Ensure learning from all complaints and incidents is embedded to ensure continuous improvement. NICE/clinical quality group now managing the process to monitor how NICE comes into the organisation and the actions required to meet NHSLA NICE policies – individual meetings being held with owners to benchmark position External compliance monitoring Regular reporting to the Healthcare Governance Sub-Committee (HGSC), Integrated Governance and Quality Committee (IGQC) and Audit Committee Board level monitoring of patient safety CQC unannounced visit August 2010 with positive outcome - Kent Lodge fully compliant with cleanliness and infection control regulations Delivery of Quality Accounts approved by the Audit Commission CQC reviewed outcome 21 - Records in light of data loss incident reported to the Information Commissioner and concluded that they had no concerns. Liverpool Service's CQC self-assessment reported to the Integrated Governance with positive assurance, and self assessments undertaken for Sefton services. Performance and quality reporting established by Division and reported to Operational Performance meetings, consolidated for Board reporting. Ongoing reporting to IGQC and HGSC Counter Fraud Specialist reports to each Audit Committee meeting. Strategic Risk:1c - Failure to meet statutory requirements e.g. Health and Safety, Human Rights Act, Equality Act, NICE/NSF, good governance or to achieve external accreditation e.g. Care Quality Commission (CQC) registration/NHS Litigation Authority Level 3 may lead to staff or patient incidents, fines or reputational damage. Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar-11 Reg 9 (Outcome 4) Reg 10 (Outcome 16) Reg 19 (Outcome 17) GMA 12 (3x4)April 201212 (3x4)

5. Strategic Objective: Working with strategic partners to provide high quality, cost effective services that are valued and recognised by patients, commissioners and the wider population ControlsGaps in ControlsMitigating ActionsPositive AssuranceGaps in Assurance Ongoing negotiation with PCTs and SHA re asset ownership, with rationale for LCH's preference. NHS premises assurance model now in place nationally. Estates, Accommodation and Facilities Management Strategy approved by the Board in July 2011. Legal input secured to draft leases and sub leases on transfer. Submission for asset split sent to SHA October 2011. Final approval for split will be obtained from DH December 2011. Work ongoing on the submitted assumptions. Project Board established with work-stream leads for each area. No asset ownership or robust licences/leases in place Strategic Health Authority (SHA) decision on transfer of assets will provide clarity concerning the LCH Estates and Facilities Management responsibility. Delivery of year 1 objectives within the strategy Identify and train building managers in appropriate procedures. Need to develop strong tenancy behaviour as per strategy in order to derive best from the accommodation. Further guidance issued by DH on 4th August which alters our assumptions and requires a further round of negotiation with PCTs Links identified for each building and Standard Operating Procedures are being developed. Continue to progress Project Board work-streams. Active engagement with DH to understand and influence likely outcome. External review of estates management commissioned to identify gap analysis with best practice to assure LCH that estates / accommodation management will be optimised regardless of the outcome of the DH decision on TCS assets. Specific briefings provided to the Board and general updates provided regularly as part of the monthly Organisational Strategy and Development Report Reported through Healthcare Governance Sub- Committee to Integrated Governance and Quality Committee to Board via minutes. Estates and Accommodation Strategy approved by the Board in July 2011. Update from Project Board submitted to FCC and reporting on the Premises Assurance Model KPIs to the FCC. Strategic Risk:1d - Poor quality and utilisation of estates/assets and inability to directly manage the estate could lead to adverse patient/staff experience/safety. Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar-11 Reg 15 (Outcome 10) Reg 16 (Outcome 11) GMA 9 (3x3)April 20129 (3x3)

6. Strategic Objective: Working with strategic partners to provide high quality, cost effective services that are valued and recognised by patients, commissioners and the wider population ControlsGaps in ControlsMitigating ActionsPositive Assurance Gaps in Assurance Policies and IG training in place Escalation procedure in place Full action plan in place to ensure compliance with policies and monitoring of exceptions Equipment for safe storage of records now in place Policy on records in storage to cover office moves Evidence of data loss, or poor data security still being reported and recorded. Risk of data loss can never be fully eliminated Monthly report submitted to Executive Team to monitor IG toolkit action plan, as well as active monitoring by the Healthcare Governance Sub- Committee and Information Governance Assurance Group. Introduction of IG Working Group and improved compliance with IG Toolkit noted in October 2011 self-assessment submission. Development of Information Asset Owners and baseline assessment complete (Oct 11) Achieved level 2 compliance at 31/3/12. IG Group continue to meet to monitor progress to level 3. Ongoing monitoring of data loss incidents. Policies in place and corporate team working with operations to deliver full compliance. All significant events reported to Board on monthly basis, including actions taken/planned to reduce risk. Achieved Level 2 standard in Information Toolkit Self Assessment in 2011/12. IG Toolkit action plan progress reports to IG Working Group and on to IGQC. Information Governance Assurance Group established and reporting up through Healthcare Governance Sub- Committee Strategic Risk: 1e - Risk of data loss due to failure of good Information Governance (IG) standards leading to adverse publicity, loss of confidence from patients/commissioners and potential loss of contracts. Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar-11 Reg 20 (Outcome 21) GMA / JOC 12 (4x3)April 20129 (3x3)

7. Strategic Objective: Working with strategic partners to provide high quality, cost effective services that are valued and recognised by patients, commissioners and the wider population ControlsGaps in ControlsMitigating ActionsPositive AssuranceGaps in Assurance Delivery of Integration Plans for acquisitions Achievement of all FT application milestones and maintenance/improvement of medium risk score with SHA performance monitoring. Monthly monitoring returns to SHA have been approved and accepted. Regular meeting cycle with SHA provider development leads now in place. Controls remain in place and all key milestones continue to be achieved, including submission and feedback on first draft IBP. Acceptance on to formal SHA/DH FT development programme Full integration of acquired services and corporate infrastructure. Programme approach to FT application process. Request for Monitor assessment manager involvement also submitted to SHA and awaiting response. Phase II and Phase III management restructure plans in place and good progress being achieved. Business planning process for draft 2 ongoing. Long- term financial model to be updated for February 2012 submission. Work-streams continue with specific action plans. Monthly Board reports Formal monitoring by SHA following sign off of Tripartite Formal Agreement (TFA) TFA now signed off by DH and positive response received from SHA re monthly monitoring returns Strategic Risk: 1f - Failure to achieve CFT status will lead to potential dispersal and/or vertical integration of community services to the detriment of patients and the health economy as a whole. Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar-11n/a BC 12 (3x4)April 20128 (2x4)

8. Strategic Objective: Working with strategic partners to provide high quality, cost effective services that are valued and recognised by patients, commissioners and the wider population ControlsGaps in ControlsMitigating ActionsPositive AssuranceGaps in Assurance Effective project management of changes. Implementation of divisions and divisional managers to lead change. Work with staff and staff side to communicate changes. No direct control over partners' financial positions e.g. Royal Liverpool and Broadgreen University Hospitals NHS Trust and Liverpool City Council Clinical governance process in place. Board approved Quality Strategy in place. Transformational change programme in place. Monthly performance meetings. Completed self-assessment of Quality Governance Framework and revise Quality Strategy for Board approval (September 2011) Effective planning and project management of changes, including business continuity and escalation planning in place for PCMS. Appropriate HR and OD support to ensure change and transition is compliant with employment legislation, Maintain partnership working with staff to communicate and explain changes planned and agree implementation processes Working with commissioners to plan service changes and proposed tenders. Working with stakeholders to ensure good engagement. Role and function of the Transformational Board has been revised. Quality breakthrough aims being developed with harm free care. Energise for Excellence is being implemented. CQUIN targets in place. Quality and performance reported to Board on monthly basis. This is now reported through the revised performance framework Positive SHA response to Francis Report submitted and reported to the Board, indicating maintenance of quality standards. Integrated performance and quality dashboard has been developed and is now reported to the Board Post-TCS integration report submitted to the Board in May 2012, outlining the successful integration of services and staff. Strategic Risk: 1g - Risk that LCH will not be able to maintain quality of operational service delivery during period of organisational change, transition, economic downturn and uncertainty leading to adverse effects for patients and potential loss of contracts and CQUIN income. Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar-11 Reg 9 (outcome 4), Reg 22 (Outcome 13), Reg 23 (Outcome 14), Reg 24 (Outcome 6). HL 12 (3x4)April 20128 (2x4)

9. Strategic Objective: Working with strategic partners to provide high quality, cost effective services that are valued and recognised by patients, commissioners and the wider population ControlsGaps in ControlsMitigating ActionsUpdated actions Nov 11Positive AssuranceGaps in Assurance Recent experience of dealing with incidents, including, pandemic flu, severe weather and riots. Major Incident, Heat wave and Fuel Emergency Plans in place, along with On- Call packs. Business continuity plans in place. Emergency planning and resilience tested recently during disturbances and Exercise Cunard. Plans reviewed and more robust. Board time out session delivered to reiterate Board's role in major incidents. Intensive training of key senior managers in emergency planning. Update business continuity plans. Testing exercise to be undertaken (Oct 2011) Provision of training to relevant staff. Emergency Planning Group in operation, reporting to Healthcare Governance Sub-Committee. Strategic Risk: 1i - Lack of emergency preparedness to respond to a major incident may prevent the delivery of high quality, cost effective care and may harm staff, patients and the public. Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Aug 11 HL 12 (3x4)April 20128 (2x4)

10. Strategic Objective: To grow our market share by being the provider of choice for established services, and by developing innovative and specialist services ControlsGaps in ControlsMitigating Actions Positive Assurance Gaps in Assurance Resource bid preparation and tenders with appropriate skills, knowledge of the process and expertise about the services and delivery models to meet requirements. Board approved bidding criteria in place. Untested Commercial strategy in place. Additional expertise and resource brought into support PCMS bid, and robust structure put in place to win bid, with budget and internally allocated resources. In-house expertise established during this bid. Successful in recent tenders and significant bid being made currently. Organisational experience in bid-making is increasing rapidly. Robust performance framework in place, with regular contract meetings and negotiation process. Service Improvement Group established for Sefton. Requested commissioning intentions from Clinical Commissioning Groups that will help inform our market strategy. Further experience gained in developing tender bids for submission. Performance Framework and service reviews support the planning and preparation for contracting meetings. Retention of key contracts including those due for renewal in 2011/12, underpinned by internal/external research demonstrating value of service where available Successful in 25% of tender bids submitted Identify appropriate tenders to bid for, ensure mechanism in place for learning from unsuccessful tender bids. Regular review of effectiveness of commercial strategy Knowsley Options contract extended for further 12 months Service reviews on key services under Any Qualified Provider currently in progress. Review market assessment as part of business planning cycle. Review commercial strategy and approval process for bid submission. Commercial strategy being updated and developed as part of business planning process. Monthly performance report provided to the Board. External monitoring of CQUIN undertaken by Liverpool PCT and reported via Finance and Commercial Committee and (via minutes) to the Board. Tender Monitoring to executive team monthly and reported to Finance and standing item at Commercial Committee Strategic Risk: 2a - Lack of ability to respond appropriately to commissioning intentions and the uncertainties in the external environment e.g. competing providers could lead to loss of funding or business or failure to win new business. Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar 1112 (3x4) HL/ GMA 12 (3x4)April 201212 (3x4)

11. Strategic Objective: To grow our market share by being the provider of choice for established services, and by developing innovative and specialist services ControlsGaps in ControlsMitigating ActionsPositive AssuranceGaps in Assurance Regular meetings in place with Local Medical Committee and Practice-based Consortia (PbC). CCG leads attend the Service Improvement Group meetings. Communication, Engagement and Marketing Strategy in place. Engagement and marketing elements need strengthening. Established relationship with PCT strategic commissioners/clinical commissioners and other partners. Divisional leads have direct links with the Commissioning leads. Commercial Manager is meeting all the Clinical Commissioning Group leads. Confidence is being developed with CCG by responding to demands. Board members are closely linked with the business community, including membership of Chamber of Commerce and Downtown Liverpool. LCH sponsored GEC event. Establish both formal and informal links and relationship with individual GPs and CCGs. Implement next phase of Communications, Engagement and Marketing Strategy Develop public involvement and membership strategy and identify resources to implement Continue to liaise with key provider partners and build up sustainable relationships, with appropriate governance arrangements where necessary. Partnership Strategy being developed for partnerships with other organisations within and external to NHS. Monthly reporting to Board via Chair and Chief Executive's report. Regular updates provided to Board for monitoring of Communications, Engagement and Marketing Strategy. Strategic Risk: 2b - Failure to establish effective relationship underpinned by robust governance arrangements with GP Commissioning, patients, public and external partners could lead to loss of business and failure to grow market share Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar-11 Reg 10 (Outcome 16), Reg 24 (Outcome 6). BC 12 (3x40April 201212 (3x4)

12. Strategic Objective: To grow our market share by being the provider of choice for established services, and by developing innovative and specialist services ControlsGaps in ControlsMitigating ActionsPositive AssuranceGaps in Assurance Board members actively involved in stakeholder management and promoting the success and reputation of the organisation. Insufficient active marketing and promotion of high quality service delivery and key achievements. No contracts lost as a result of poor performance and no current significant performance issues. Quality priorities agreed for 2011/12 Robust performance framework in place, with monthly performance meetings for each division. Establish use of Patient Choices website/LCHT internet to obtain patient ratings Identify baseline and key performance indicators as part of Quality Strategy for patient experience On target to achieve contract Currently running at 40% achievement. Partially completed though awaiting data. Monthly reporting to Board on performance and quality indicators Strategic Risk: 2c - Poor service performance could lead to loss of reputation and loss of contracts/failure to win new business Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar-11 Reg 10 (Outcome 16) HL 12 (3x4)April 20128 (2x4)

13. Strategic Objective: To grow our market share by being the provider of choice for established services, and by developing innovative and specialist services ControlsGaps in ControlsMitigating ActionsPositive AssuranceGaps in Assurance Learning and Development Bureau in place with full training programme PDR processes in place Core competency work programme being rolled out. LCH successful in winning awards LCH have won contracts on the back of innovation and service development Research and Development (R&D) strategy developed and R&D lead in place. Lack of systematic approach to stimulate, record and market innovations in LCH successful in winning awards Commitment given for EMIS implementation. System in place for supporting innovation across the organisation. LCH participating in the Dallas programme, in partnership with Liverpool PCT and Riverside Housing. Updated Board approved Technology and Innovation Strategy in place, with increased use of mobile working, telehealth/telemedicine implementation and adoption of technology by Board (iPads and twitter etc) Introduce corporate mechanism that stimulates, records and markets innovation to deliver this year's objectives outlined in the Technology and Innovation Strategy. (July 11) Process has been developed, but streamlined web based approach being developed Continue to review telehealth and exploration of mobile working. Continue roll out of electronic records. Progress work LCH is leading on for telehealth and proactive care. Innovation Workshop led by LCH held with staff and external contacts. Well received and positive responses. Reported through Clinical Quality Group to HGSC and through to Board via IGQC minutes submitted following each meeting. LCH successful in winning awards Technology and Innovation Strategy approved by Board in January 2012. Strategic Risk: 2d - Failure to innovate and keep up with pace of change in market environment and technology, contributing to failure to win targeted contracts. Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar-11 Reg 21, (Outcome 12), Reg 23 (Outcome 14) GA/HL 9 (3x3)April 20129 (3x3)

14. Strategic Objective: To reduce health inequalities and improve health in communities by developing as a public health organisation ControlsGaps in ControlsMitigating ActionsPositive AssuranceGaps in Assurance Ability to identify LCH's share of contribution to long-term health improvement in contracts and CQUIN target Currently on track to deliver commissioned public health targets. Signed up to chronic obstructive pulmonary disease (COPD) pathway and Adult Nursing Specification. Significant improvement with vaccination and immunisation targets and overachieving on chlamydia screening target. Public Health Strategy approved by the Board in November 2011. Health interventions delivered. LCH have a dedicated Public Health Consultation. In the process of developing into a public health organisation with the delivery of ‘every contact counts’ and public health nurse specialists in health visiting and school health. Achieve LCHT contribution to national targets, including all vaccination and immunisation targets for 2011/12 Establish baseline to measure quantity and type of public health interventions by LCHT in order to demonstrate year on year improvements Health impact assessment being undertaken completed. Regular reporting to Healthcare Governance Sub- Committee and Board Reported to Board through performance framework Public Health Strategy Group reports to the Transformational Change Board and quarterly updates provided to the Board. Strategic Risk: 3a - Inability to demonstrate LCHT’s contribution to long term health improvement leading to potential loss of contractual and CQUIN income Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar-11 Reg 9 (outcome 4) HL 12 (4x3)April 20129 (3x3)

15. Strategic Objective: To reduce health inequalities and improve health in communities by developing as a public health organisation ControlsGaps in ControlsMitigating ActionsPositive AssuranceGaps in Assurance Ability of LCH to influence partnership working and risk sharing. Multiagency project on intermediate care and front end QIPP programme. Partnership with GPs and GP commissioners on Adult Services Legal contracts in place for recent/established bids delivered in partnership. Regular discussions ongoing with partners' governance leads. Ensure robust governance and performance management arrangements to support partnership working and where pooled budgets are in place (July 11) Work with Liverpool City Council to develop and implement integrated re-ablement services "Identify specific key performance measures to demonstrate LCH contribution to integrated care pathways: - Decreased admissions - Increased patient satisfaction - Reduced duplication - High quality services Approach to governance arrangements will be incorporated in the Commercial Strategy being developed. Lack of robust reporting through to Board Programme management of front end QIPP and Intermediate Care in place Reported through performance framework to Board Strategic Risk: 3b - Lack of robust governance and risk sharing arrangements for partnerships and joint working may lead to significant financial and reputational risk. Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar-11 Reg 10 (Outcome 16) HL 12 (4x3)April 2012

16. Strategic Objective: To attract, retain, continue to develop and protect a diverse, motivated and flexible workforce, with the skills and competencies to deliver organisational success ControlsGaps in ControlsMitigating ActionsPositive Assurance Assurance gaps BME target to reflect local population in place. Local employment initiatives in place with good uptake. Monitoring, reporting and action planning of all aspects of diversity takes place, and single equalities scheme has been agreed. Staff networks are in place. Additional constraint due to lack of staff turnover, the financial challenges and new recruitment in current climate, reputation of NHS as an employer may be affected by changes to terms and conditions e.g. pensions review EPIT EDS assessment of "achieving“ Ongoing engagement with staff including staff survey for all employees, staff awards, employee of the month, breakfast with Bernie, staff charter engagement and back to the floor programme. Cadet scheme in place, with local recruitment. Strong partnership with staff side in place. Identify and implement opportunities for improving the diversity of the workforce through annual engagement analysis and plan. Action plans to be developed for all divisions linked to EDS feedback. Implement staff survey action plans. Strategic workforce planning underway for all divisions. Analysis of workforce initiatives being undertaken. Skill mix and workforce modernisation initiatives to be fully analysed and where appropriate adopted. Explore possibilities of positive action via HR&OD Committee Explore opportunities for apprentices. Pro-active recruitment for staff bank to reduce dependence on agencies and create capacity. Staff networks being reviewed. Workforce being mapped to local community figures. Demographics of our workforce, community footprint and stakeholders/partnerships currently being mapped to identify key priority areas (KPAs). Workforce indications included in Integrated Performance and Quality Dashboard and Report provided to the Board on a monthly basis. HR & OD Committee monitor targets and report to Board via minutes and highlight reports. Workforce Strategy submitted to Board in April 2012 Strategic Risk: 4a - Failure to attract, retain and develop a flexible, diverse and skilled workforce will adversely affect the ability to become the employer of choice and deliver against Commissioners’ needs. Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar-11 Reg 21, (Outcome 12), Reg 22 (Outcome 13), Reg 23 (Outcome 14) NB 9 (3x3)April 20129 (3x3)

17. Strategic Objective: To attract, retain, continue to develop and protect a diverse, motivated and flexible workforce, with the skills and competencies to deliver organisational success ControlsGaps in ControlsMitigating ActionsPositive AssuranceGaps in Assurance Strategic workforce future planning in place to determine workforce skill mix required. Revised Mandatory training Policy in place. Targets established for improvement in uptake of mandatory training and greater flexibility of delivery to meet target. Implementation of e-learning options for training. Structure in place to deliver HV recruitment drive and delivered target for 2012 Significant improvement in compliance with mandatory training. Robust workforce planning including development of revised Workforce Strategy. Adopt skill mix and modernisation initiatives to create a flexible, responsive workforce. Develop 5 year plan to deliver our workforce of the future. Planned leadership development and HV recruitment planning in place for 2012/13. Achievement of 4% or less sickness absence rates New PDR process, documentation and training to be launched July 2012. Training and Development review and restructure underway to redefine strategic priorities and support the delivery of organisational objectives Full review of mandatory training to be undertaken and key requirements addressed Develop costed annual training needs priorities plan and deliver Staff to be 100% compliant with mandatory training Continued expansion of e-learning, readers and delivery flexibility to increase compliance and reduce impact on operational delivery. Workforce indications included in Integrated Performance and Quality Dashboard and Report provided to the Board on a monthly basis. HR & OD Committee monitor targets and report to Board via minutes and highlight reports. Workforce Strategy submitted to Board in April 2012 Strategic Risk: 4b - Lack of investment in development and training will have an adverse effect on the organisation's ability to attract and retain the right workforce, to provide a flexible response to the changing environment and lead to failure to become the employer of choice. Date added CQC ref OwnerInitial risk (Likelihood x Consequence)Date reviewedRisk following review (LXC) Mar-11 Reg 10 (Outcome 16), Reg 21 (Outcome 12), Reg 22 (Outcome 13), Reg 23 (Outcome 14). MP 9 (3x3)April 20129 (3x3)