MANDATORY TRAINING POLICY POLICY · Title: Mandatory Training Policy Version 9.1 Issued: 1st July...

Title: Mandatory Training Policy Version 9.1 Issued: 1

st July 2019 of 15

MANDATORY TRAINING POLICY

POLICY

Reference LR TED

Approving Body TED Committee

Date Approved 6th June 2019

Issue Date 1st July 2019 – minor amend approved 9th Dec 2019

Version 9.1

Summary of Changes from Previous Version

Safeguarding level 3 now included in Think Family Day. ODPs now require blood transfusion training. MCA levels 1 and 3 training included from Dec 2019.

Supersedes

Version 9

Document Category Human Resources

Consultation Undertaken

Specialist leads and TED Committee

Date of Completion of Equality Impact Assessment

10th May 2019

Date of Environmental Impact Assessment (if applicable)

N/A

Legal and/or Accreditation Implications

To meet NHSLA standards, national legislative requirement and National Core Skills Mandatory Training Frameworks

Target Audience All SFH employees

Review Date 1st July 2021

Sponsor (Position)

Executive Director of HR & OD

Author (Position & Name)

Deputy Director for Training, Education and Organisational Development

Lead Division/ Directorate

HR

Lead Specialty/ Service/ Department

Training & Education

Position of Person able to provide Further Guidance/Information

Deputy Director for Training, Education and Organisational Development

Associated Documents/ Information Date Associated Documents/ Information was reviewed

N/A


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CONTENTS

Item Title Page

1.0 INTRODUCTION 3

2.0 EXECUTIVE SUMMARY 3

3.0 POLICY STATEMENT 3

4.0 DEFINITIONS/ ABBREVIATIONS 3

5.0 ROLES AND RESPONSIBILITIES 4

6.0 APPROVAL 6

7.0 DOCUMENT REQUIREMENTS 6

8.0 MONITORING COMPLIANCE AND EFFECTIVENESS 7

9.0 TRAINING AND IMPLEMENTATION 8

10.0 IMPACT ASSESSMENTS 9

11.0 EVIDENCE BASE (Relevant Legislation/ National Guidance) and RELATED SFHFT DOCUMENTS

9

12.0 APPENDICES 10

APPENDICIES

Appendix 1 Equality Impact Assessment 10

Appendix 2 Risk Management Training Matrix 13


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1.0 INTRODUCTION It is vital that all staff have up to date information on legislation and professional standards, along with skills appropriate to their role.

The Trust acknowledges that given the high workload and pressures on the service a realistic, achievable approach must be adopted to ensure that risks are minimised and staff remain up to date in their knowledge and skills.

It is also important that this training is provided to staff in different ways in order to improve accessibility. For some mandatory courses e-learning or workbook resources are available. The Corporate Induction programme for new starters includes some key mandatory training requirements. This ensures that staff new to the Trust are brought into the mandatory training process which is applied to all existing staff.

This policy is issued and maintained by the Executive Director of Human Resources and OD on behalf of the Trust and supersedes and replaces all previous versions.

2.0 EXECUTIVE SUMMARY The Trust is committed to Mandatory Training as a means of assisting the organisation to meet statutory and legal obligations, manage risks and maintain standards of patient care. The Trust is committed to ensuring that none of its policies, procedures and guidelines discriminate against individuals directly or indirectly on the basis of gender, colour, race, nationality, ethnic or national origins, age, sexual orientation, marital status, disability, religion, beliefs, political affiliation, trade union membership, and social and employment status. An equality impact assessment (EIA) of this policy has been conducted by the author using the EIA tool developed by the Diversity and Inclusivity Committee. 3.0 POLICY STATEMENT This Mandatory Training Policy sets out the mandatory training employees need to undertake to meet statutory and legal obligations, manage risks and maintain standards of patient care. 4.0 DEFINITIONS/ ABBREVIATIONS For the purpose of this policy Mandatory Training is defined as training approved by the Trust as essential to comply with legislation or to maintain key standards in patient care.


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5.0 ROLES AND RESPONSIBILITIES Divisional Management Teams are responsible for ensuring that: Local compliance of mandatory training targets are monitored and progress against targets are discussed at Divisional Performance review meetings. Line Managers are responsible for ensuring that:

Staff are informed of the mandatory training requirements relevant to their post at the time of induction period and that all mandatory training identified is undertaken with 100% compliance expected. Managers will ensure that sufficient time is made available to staff to undertake their mandatory training.

Staff on short term contracts or staff that have changed roles within the Trust receive, as part of their induction, information and time to undertake the training necessary for them to carry out their role effectively and safely. See Local Induction policy section 4.6.

The impact of mandatory training on clinical governance/risk management processes is evaluated through the annual Training, Education and Development Report. Individual staff members are responsible for ensuring that: Their knowledge and skills are up to date in accordance with mandatory training requirements, for continuing professional development/lifelong learning and the requirements of their role. Each individual is responsible for ensuring that they are booked onto and attend the mandatory training courses, relevant to their post, within the required timescales as identified in Appendix 2 and in advance of their existing mandatory training record elapsing. Each individual should give full commitment to attending all appropriate mandatory training on the day allocated, they will attend the programme in accordance to published times and promptly rearranging the date if absolutely necessary. Apply the knowledge and skills acquired from mandatory training at all times and alerting line manager if any aspects of practice contravenes the advice given and guidance provided on the training.

Training, Education and Development Department is responsible for ensuring that:

A review of mandatory training needs will be undertaken on a bi-annual basis to ensure compliance with NHSLA standards and the National Core Skills Mandatory Training Framework. The review process will consider inputs, developments and recommendations from the Training, Education and Development Department and Committee, Specialist Training Leads as to what courses, staff groups, departments and frequency of training should be included in the Mandatory Training Policy to support organisational needs and changes in national guidelines.


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The policy is reviewed on a 2 yearly basis and inputs from these groups will also form part of the policy review and consultation process. The range and availability of training courses will be incorporated into the Trusts Training Manual (prospectus) which is available on the Training, Education and Development department’s Intranet site. The Mandatory Training Policy is reviewed and updated as required by the Training, Education and Development Committee in consultation with other key staff and approved by the TED Committee. Before approving the policy, the Training, Education and Development Committee will verify that all of the topics contained within the NHSLA and National Core Skills Mandatory Training Framework minimum TNA minimum data set and other national standards have been included in the policy. The Committee will also ensure that appropriate training plans and capacity have been developed to meet the needs of the Trust. Attendance information is recorded of all mandatory training delivered on the Trust's OLM reporting system. The Department will provide information on attendance and staff failing to complete mandatory training courses to the divisions on a monthly basis as part of the Trust's approach to performance management.

Mandatory training reports are provided by the Training, Education and Development Department for monitoring to the Trust Board on a monthly basis.

The Information and Quality team within the Training, Education and Development Department will undertake a 6 monthly audit of 20 permanent members of staff during the last 6 months to ensure that:

• Staff attending training courses have been accurately recorded onto the OLM training database and online training prospectus is current. • Identification of staff who had booked onto a mandatory update course but failed to attend were sent follow up letters and that they subsequently had completed their mandatory update training course. • That plans to deliver mandatory training courses are contained on the departments Intranet site.

Key Trainers Where training is delivered through Link Trainers in the work place, it is the responsibility of the appropriate key trainer to ensure that records are maintained of all training delivered and are submitted promptly to the Training Department for inclusion on the database. Link trainers will take responsibility for ensuring that their own professional training remains current.


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The Training Department will issue a list of report cut off dates to all link trainers up to 1 year in advance to ensure the timely return of all training registers in order to be inputted onto the OLM system. 6.0 APPROVAL

The Training, Education and Development Committee is responsible for approving this policy. 7.0 DOCUMENT REQUIREMENTS The Trust has considered the training needs of its staff and determined which are considered to be mandatory. The staff groups identified to receive mandatory training and the frequency required are detailed in Appendix 2. Staff who attend the Trust Induction Day or Mandatory Update need not attend similar individual training sessions which have already been covered in the Induction Day or Mandatory Update until a further update is due as listed in Appendix 2. For staff with short term contracts their line manager will assess what information and training should be provided as part of their induction. When doing this line managers will take into account records of any previous and recent training the member of staff has received. Line managers must ensure that staff are able to carry out their role effectively and safely, and to comply with relevant legislation and professional standards. Where short term contracts of staff are extended line managers must decide at what point the requirements of this policy will be applied to the member of staff. The policy does not cover mandatory training requirements for continuous professional development purposes for specific staff groups or individuals. These requirements will be managed within Divisions for each professional staff group.


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8.0 MONITORING COMPLIANCE AND EFFECTIVENESS

Minimum Requirement

to be Monitored

(WHAT – element of compliance or

effectiveness within the document will be

monitored)

Responsible Individual

(WHO – is going to monitor this element)

Process for Monitoring

e.g. Audit

(HOW – will this element be monitored (method used))

Frequency of

Monitoring

(WHEN – will this element be monitored

(frequency/ how often))

Responsible Individual or Committee/

Group for Review of Results

(WHERE – Which individual/ committee or group will this be reported to, in what format (eg

verbal, formal report etc) and by who)

2 yearly

Deputy Director Training Education and Organisational Development

People, OD and Culture Committee monitoring of Mandatory training compliance against Trust mandatory training target. Divisions will monitor local level compliance through divisional governance structures and Performance Meetings.

Quarterly

Deputy Director Training Education and Organisational Development

Title: Mandatory Training Policy Version: 8 Issued: 1

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9.0 TRAINING AND IMPLEMENTATION Managers will be given updates on expectations of the Trust Mandatory Training requirements through the Training, Education and Development Department and Managers Induction and development programmes. Corporate Induction and mandatory training courses are organised in sufficient capacity to meet the needs of the Trust based upon staff numbers and staff groups identified in the OLM (Oracle Learning Management system) mandatory training reports. The Professional Education and Training team will plan and develop a programme of training events of up to 1 year in advance which will be published on the Training Department’s intranet site. Some mandatory training is provided in different ways offering flexibility of access e.g. E-learning or the use of workbooks. Support surgeries for staff struggling to complete their mandatory training are also provided. Implementation of the policy will be monitored through the Divisional Performance Monitoring process to ensure that the Trust’s staff receive appropriate training/updating of knowledge and skills within the timescale agreed. Details of staff applying for and attending of all in-house training activities are entered onto the Training Department’s OLM database from training course attendance registers. Following each course the database is updated with lists of attendees and those who fail to attend. Where staff fail to attend a mandatory update training course, a letter is sent to line managers by the Training Department asking them to contact the Training Department to arrange an alternative date. Monthly performance and non-compliance reports will be provided by the Training, Education and Development Department to managers in order to monitor local performance management and compliance of the Policy. The Trust Board will receive monthly statistical reports from the Training, Education and Development Department for Trust wide monitoring of compliance with the policy. The Trust is committed to ensuring that it meets the standards set out in the NHSLA, National Core Skills Mandatory Training Frameworks and other national requirements and the monitoring tables below indicate how this policy meets these required standards. Staff that fail their mandatory training pre-course workbook more than 3 times will be referred to their line manager as this will be considered a capability issue. Pay progression is linked to the completion of all relevant mandatory training and will be sense checked during the appraisal process. Staff who are out of date with their mandatory training at the time of their appraisal with not receive their pay increment, unless there are valid reasons for non-compliance.



10.0 IMPACT ASSESSMENTS

This document has been subject to an Equality Impact Assessment, see completed form at Appendix 1

This document is not subject to an Environmental Impact Assessment 11.0 EVIDENCE BASE (Relevant Legislation/ National Guidance) AND RELATED SFHFT DOCUMENTS Evidence Base:

Safeguarding Children & Young People Policy – 2016

Safeguarding Adults Policy 2015 and National Intercollegiate Standards

Cardiopulmonary Resuscitation Training Policy and Resuscitation Council requirements - 2014

Medical Equipment User Training Policy - 2016

Policy on the Induction of Staff – 2016

NHSLA Standards.

National Skills for Health Mandatory Training Core Skills Framework

GMC Risk Management Standards

CNST Maternity Standards

National Bribery Act

NICE Guidelines

BSQR and national Blood Committee for standards in Haematology Guidelines

NHS Protect National Requirements

Civil Contingencies Act 2015 Related SFHFT Documents:

NA 12.0 APPENDICES

Appendix 1 Equality Impact Assessment

Appendix 2 Risk Management Training



APPENDIX 1 - EQUALITY IMPACT ASSESSMENT FORM (EQIA)

Name of service/policy/procedure being reviewed: Mandatory Training Policy

New or existing service/policy/procedure: Existing

Date of Assessment: 10/5/2019

For the service/policy/procedure and its implementation answer the questions a – c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)

Protected Characteristic

a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups’ experience? For example, are there any known health inequality or access issues to consider?

b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening?

c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality

The area of policy or its implementation being assessed:

Race and Ethnicity

Yes The policy has been designed to ensure equality for all staff when undertaking their mandatory training

None

Gender


None

Age


None

Religion Yes The policy has been designed to ensure equality for all staff when undertaking their mandatory training

None

Disability

Yes The policy has been designed to ensure equality for all staff when undertaking their mandatory training. The online booking system asks staff to indicate any special requirements,

None



to alert the course facilitator. All staff are asked if they have any moving and handling issues at the start of the practical day and adjustments are made accordingly.

Sexuality

Yes The policy has been designed to ensure equality for all staff when undertaking their mandatory training.

None

Pregnancy and Maternity

Yes The policy has been designed to ensure equality for all staff when undertaking their mandatory training. The online booking system asks staff to indicate any special requirements, to alert the course facilitator.

None

Gender Reassignment


None

Marriage and Civil Partnership


None

Socio-Economic Factors (i.e. living in a poorer neighbourhood / social deprivation)


None

What consultation with protected characteristic groups including patient groups have you carried out?

Discussed with and reviewed by Trust Diversity and Inclusivity Lead

What data or information did you use in support of this EqIA?

NHSLA standards and core skills frameworks



As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments?

No

Level of impact Level of Impact/Low Level of Impact

Name of Responsible Person undertaking this assessment: Lee Radford

Signature: Lee Radford

Date: 10th May 2019



Appendix 2 - Risk Management Training Matrix Course Alcohol,

Drugs & Tobacco Brief Interventions

Basic Life Support Assessments Level 2

Blood Transfusions Update (Theory)

Conflict Resolution

Counter Fraud Equality, Diversity & Inclusivity

Fire Lecture Hand Hygiene Levels 1 and 2

Health & Safety at Work

Information Governance

Frequency Every 12 months

Every 12 months

Every 2 years Every 3 years Every 3 years Every 3 years Every 12 months

Every 12 months

Every 3 years

Every 12 months

Driver NICE Guidance

National Core Skills Framework

BSQR and national Blood Committee


National Bribery Act






Delivery Method E-learning – 15 minutes

Face to Face 60 minutes

Face to Face and E-learning 60 minutes

Face to Face 3 hours

E-learning 20 minutes


F2F or EL 30 minutes


E-Learning 30 minutes

F2F or EL 1 hour

Registered and Associate Nurse/Midwives

F2F Excluding all specialist and research nurses, MCH wards and KTC staff

Excluding theatre nurses

Health Care Support Multi skilled Workers

F2FExcluding MCH and KTC staff

Excluding theatre HCAs

Permanent Medical Staff EL -Relevant staff who prescribe or take blood samples or administrate

Radiographers

Pharmacy Patient facing Excluding non registered

Excluding non registered

Pathology Staff

MEMD Staff

Therapy Services Staff Excluding Assistants

Cardio respiratory Staff

Audiology

Orthoptist

Ward House Keepers/Receptionists

Chaplains

Operating Theatre Practitioners

Non Clinical and technical Staff inc Executive Directors, NEDs, Governors and Volunteers

Patient facing admin staff only

Level 1 - only Every 3 Years



Course Major Incident Medical Equipment

Mental Capacity Act Level 1

Mental Capacity Act Level 2 and Level 3

Moving and Handling Level 1 and 2

MRSA / CDIFF

Medicines Management

Prevent Prevent WRAP


Every 12 months

Every 12 months

Once followed by yearly update

Every 12 months

Every 3 years Every 12 months

Every 12 months

Once

Driver Civil Contingencies Act


National Care Act National Care Act


Trust NHSLA National Core Skills Framework


Delivery Method E-learning – 15 minutes



E-learning Initial 1.5 hrs Update 20 minutes

Face to Face 1 hour




Face to Face/E-learning 15 minutes


Level 2 Patient Excluding OH nurses

Health Care support multi skilled Workers

Level 2 Patient

Permanent Medical Staff Every 3 years E-Learning

Radiographers Level 2 Patient

Pharmacy patient facing Excluding non registered

Level 1 object

Pathology Staff Level 1 object

MEMD Staff Level 1 object – Every 3 years

Therapy Services Staff Level 2 Patient

Cardio respiratory Staff Level 2 Patient

Audiology Level 2 Patient

Orthoptists Level 2 Patient


Level 1 object

Chaplains Level 1 object


Level 2 Patient

Non Clinical and technical Staff inc Executive Directors, NEDs, Governors and volunteers

As from Nov 19 through new Intercollegiate Standards (inc Safeguarding Training)

Level 1 object theory Every 3 years

Every 3 years



Course Safeguarding Adults Level 1

Safeguarding Adults Level 2

Safeguarding Adults Level 3

Safeguarding Children Level 1




Slips, Trips and Falls

Tissue Viability


Every 12 months

Every 3 years plus annual level 2 update

Every 12 months

Every 12 months

Every 3 years Every 3 years Every 12 months

Every 12 months

Driver National Care Act



National Care Act


National Care Act


NHSLA NHSLA

Delivery Method E-Learning 30 minutes


Face to Face Full Day

E-learning – 30 minutes

E-Learning 1 hour

Face to Face Full Day

Face to Face 1 hour




Excluding Paediatric, Midwives, IHSH nurses

ED, Paediatric midwives, IHSH Nurses only

Named Safeguarding Nurse only

Excluding Paediatric Nurses

Excluding Paediatric Nurses

Health Care Support multi Skilled Workers

Permanent Medical Staff Excluding Paediatric

Covered in Level 3 training

ED, Paediatric only

Named Safeguarding Dr only

Radiographers

Pharmacy Patient facing

Pathology Staff

MEMD Staff

Therapy Services Staff

Cardio respiratory Staff

Audiology

Orthoptists


Chaplains


Non Clinical and technical Staff inc Executive Directors, NEDs, Governors and Volunteers

MANDATORY TRAINING POLICY POLICY · Title: Mandatory Training Policy Version 9.1 Issued: 1st July...

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