The Newcastle Upon Tyne Hospitals NHS Foundation Trust Version No.: 10.0 Effective Date: 1 st July 2012 Expiry Date: 30 th June 2015 Date Ratified: 6 th June 2012 Ratified By: Executive Team Mandatory Training Policy 1. Introduction This policy sets out those training requirements determined by the Trust as being mandatory (i.e. training which must be attended by staff), the employees to whom training applies, and the frequency which training must be undertaken and the responsibilities of those involved. Paid study leave will be granted to all employees undertaking mandatory training. 2. Scope 2.1 The Trust is responsible for ensuring that all employees are appropriately trained. This is to enable them to undertake their duties and responsibilities, meet health and safety requirements, protect their own wellbeing and help ensure patient safety. This policy applies to all staff, including the nurse and administration bank and volunteers. The mandatory training requirements for staff by role are set out in Appendix 1 & 2. 2.2 Identification of new mandatory training requirements from policy/legislation change must be discussed with the Head of Education and Development in the first instance prior to agreement by the Trust Education Board and Executive Team. 3. Aims To ensure that all staff are aware of the mandatory training that they must undertaken and how often. 4. Duties roles and responsibilities 4.1 Directorate/Departmental Managers/Clinical Directors/line managers 4.1.1 Are responsible for ensuring that staff are allocated time to attend mandatory training including those identified by risk assessments where appropriate and Appendix 1 of this policy. 4.1.2 Must ensure that applications for funding to attend external training events are not submitted to the Education and Training Department for Page 1 of 10
approval without confirmation that mandatory training has been completed, or training dates allocated. 4.1.3 Will identify department/directorate mandatory training requirements using the matrix in Appendix 1, and ensure compliance is met at all times. 4.1.4 Are responsible for following up Did Not Attend (DNA) notifications within their service, ensuring the relevant staff re-attend the required training 4.1.5 Are responsible for ensuring that accurate records are maintained at local level in order to monitor compliance with this policy. 4.1.6 Are responsible for ensuring that accurate registers (using standard register template) for any locally provided mandatory training are returned to the Education and Training Department within five working days of the training being completed for recording on Training Manager Pro (TMP). 4.1.7 Are responsible for ensuring that mandatory training requirements and completion of these are agreed and documented as part of the staff annual appraisal process 4.2 Employees 4.2.1 Are responsible for ensuring they attend mandatory training required for their role on the dates agreed unless prevented from doing so. 4.2.2 Must ensure that mandatory training has been completed, or a place has been allocated on all relevant programmes, prior to seeking approval for paid leave/expenses to attend non-mandatory external training events. 4.2.3 Should be aware that failing to attend mandatory training events as allocated to them for reasons other than the need to cover unplanned service demands or sickness absence, may lead to disciplinary action. 4.2.4 Who fail to attend a pre booked session, and have not cancelled within 24 hours will be deemed to be a DNA (did not attend) and will receive written notification of this, copied to their manager. 4.2.5 New starters should complete all online mandatory training within seven days of commencement (with the exception of junior/let doctors, who shall complete their training within one month). 4.2.6 Who are not fully compliant with their mandatory training will be not be eligible for study leave (including conferences and events) and may also have their pay increment deferred as a result of an unsatisfactory appraisal outcome. Page 2 of 10
4.3 Trust Education and Training Department / mandatory training providers 4.3.1 The Trust Education and Training Department is responsible for maintaining accurate records of all staff completing mandatory training, and providing monthly summary reports to the Trust Executive and Directorates. All mandatory training listed within Appendix 1 will be recorded using TMP. 4.3.2 Mandatory training providers are responsible for ensuring that accurate registers are maintained of all employees completing training delivered directly by them, including DNAs and that registers are returned to the Education and Training Department within five working days of the training event taking place to ensure accurate and timely recording of training. 4.3.3 The Education and Training Department will coordinate the scheduling of all centrally provided mandatory training and the annual training plan. Mandatory training providers will contribute to this process through taking responsibility for scheduling and provision of cascade training. 5. Definitions 5.1 Clinical staff are defined as doctors, dentists, nurses, midwives, health visitors, health care assistants, allied health professionals (including helpers), pharmacists, scientists, psychologists, physicians and other persons who are involved in the direct care or provision of clinical services to patients. Clinical support staff includes porters and technical support where indicated. 5.2 Mandatory training is training which is required of particular staff groups and which has been mandated by legal or national statute, by an appropriate regulatory body (e.g. NHSLA, Monitor etc) or by the Trust, partner or national/international authority in accordance with its guidance or requirements. 6. Attendance records for mandatory training 6.1 Attendance at all mandatory training programmes for all staff is monitored by the Education and Training department. This will include DNA rates for pre bookable programmes. This data is the only source data to be used for Directorate performance reviews and quarterly reports to the Trust Education Group, Trust Executive and Trust Board. 6.2 A supervisor shall be defined as a person with direct responsibility for authorising the attendance of staff on mandatory and non-mandatory training and shall be, unless requested otherwise, be in accordance with the Manager Self Service hierarchy as defined by ESR. It is the responsibility of supervisors to update the Education and Development team with any changes to their personal hierarchy. Page 3 of 10
7. Training Training will be provided by the Human Resources Department to managers following implementation of the policy. 8. Equality and Diversity The Trust is committed to ensuring that, the way services are provided to the public and the staff are treated reflects their individual needs and does not unlawfully discriminate against individuals or groups on any grounds. This policy has been assessed accordingly. 9. Monitoring compliance with the policy Standard/Process/Issue Monitoring and Audit Method By Committee Frequency a. Production of daily Automated Education TEG Quarterly DNA reports. These reports will be emailed to the appropriate supervisor. report generators Centre Administrators b. Courses will be added to the Training Needs list of staff who DNA. This training need will appear on staff TMP Online pages, allowing them to rebook. Supervisors will also see this training need. Supervisors will also be sent a report of training needs. Automated report generators Education Centre Administrators TEG Quarterly c. Monitor bookings and send reminders to staff who have not rebooked. d. Production of monthly training reports (including DNA) for directorate monitoring Automated report generators Highlight Report from training data Education Centre Administrators Education Centre Administrators TEG TEG Quarterly Monthly Page 4 of 10
e. Production of training, compliance, activity and attendance reports f. Review of mandatory training needs, refresh and update requirements. g. Top level dashboard reporting will be available to designated supervisors and directorate managers through Training Manager Online. Highlight Report from training data Review Intranet Head of Education and Development Head of Education and Development All supervisors TEG Trust Education Board TEG and Trust Board Quarterly Annual Quarterly 10. Consultation and review of this policy This policy has be reviewed in consultation with the Trust Education Group, Clinical Governance Group and the Employment Policies and Procedures Consultative Group. 11. Implementation of the policy (including raising awareness) A summary of the key changes will be notified to managers following implementation. Further advice and guidance will be available from the Human Resources Department. Author: Head of Education and Development Page 5 of 10
Appendix 1 Course Delivery Clinical Support Services Staff Admin & Clerical Allied Health Professionals Ancillary Staff Building & Maintenance Laboratory Staff Groups Pharmacy Professional and Technical Medical Dental Nursing & Midwifery, District Nurse Health Visitors School Nurses Matrons/Nurse Consultants Adult Basic Life Support Taught or Blended session A A A* A* A A A A A Paediatric BLS Taught or Blended A(P) A(P) A(P) A(P) A(P) A(P) A(P) A A(P) session Blood Transfusion Awareness Taught session IN-A IN-A IN-A* IN-A Blood Transfusion Collection & Delivery Taught session IN-2 IN-2 IN-2* IN-A Competence Assessment Blood Transfusion Administration Competence E-Learning IN-3 IN-3 IN-3* Assessment Blood Transfusion Specimen Taking E-Learning IN-3 IN-3 IN-3* IN-3 Competence Assessment Complaints Handling Induction IN IN IN IN IN IN IN IN IN IN IN IN IN Equality and Diversity Awareness Induction/ e-learning IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 Fire Awareness e-learning IN-A IN-A IN-A IN-A IN-A IN-A IN-A IN-A IN-A IN-A IN-A IN-A IN-A IN-A Food Hygiene Awareness Induction/ e-learning IN-3 IN-3 IN-3 Health & Safety at Work Induction IN IN IN IN IN IN IN IN IN IN IN IN IN IN Incident Reporting Induction IN IN IN IN IN IN IN IN IN IN IN IN IN IN Induction (Corporate) Classroom (e- Learning for Jnr Drs) IN IN IN IN IN IN IN IN IN IN IN IN IN IN Induction (Local) Checklist (intranet) IN IN IN IN IN IN IN IN IN IN IN IN IN IN Infection Prevention and Control non-clinical e-learning IN-A IN-A IN-A IN-A IN-A IN-A Infection Prevention and Control Clinical Level 2 e-learning IN-A IN-A IN-A Infection Prevention and Control Dental e-learning IN-A Information Governance for Regular Data Handlers Information Governance Annual Refresher for Regular Data Handlers Information Governance for non-regular handlers Induction/ e-learning IN IN IN IN-NP (AfC6+) IN IN IN IN IN IN IN IN IN e-learning A A A A-NP (AfC6+) A A A A A A A A A Taught session Once Once Manual Handling Awareness Induction IN IN IN IN IN IN IN IN IN IN IN IN IN Manual Handling: Display Taught session 3 3 3 3 Screen Assessors Manual Handling (Objects) Or IN-2 if relevant Or IN-2 if relevant Taught session IN-2 IN-2 IN-2 to role to role Manual Handling (Office) Taught session IN-3 IN-2 IN-2 IN-3 IN-3 IN-2 Non-Clinical Senior Managers Page 6 of 10
Appendix 1 Course Delivery Clinical Support Services Staff Admin & Clerical Allied Health Professionals Ancillary Staff Building & Maintenance Laboratory Staff Groups Pharmacy Professional and Technical Medical Dental Nursing & Midwifery, District Nurse Health Visitors School Nurses Manual Handling (Patients) Taught session IN-2 IN-2 IN-2 IN-2 IN-2 Manual Handling (Static Posture) e-learning Oph-A A Manual Handling Facilitators Taught session Object 2 2 2 2 2 2 2 Manual Handling Facilitators Taught session Patients A A A A A A Safeguarding Adults and Children Level 1 Safeguarding Children Level 2 Safeguarding Children Level 3 Induction/ e-learning NSCB e- Learning or multi-agency taught session or singleagency face to face session Matrons/Nurse Consultants IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 PLEASE SEE APPENDIX 2 PLEASE SEE APPENDIX 2 Saving Lives Module e-learning Once Once Once Once Once Slips Trips and Falls all staff Induction IN-Once IN-Once IN-Once IN-Once IN-Once IN-Once IN-Once IN-Once IN-Once IN-Once IN-Once IN-Once IN-Once IN-Once Slips Trips and Falls clinical staff e-learning Once Once Once Once Once Once Violence and Aggression Breakaway Taught session A-RA A-RA A-RA A-RA A-RA A-RA A-RA Violence and Aggression - Conflict Resolution e-learning 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Violence and Aggression Control and Restraint Taught session A Porters A-Security Staff COSHH Taught session A-NP A-NP A-NP A-NP A-NP A-NP A-NP A-NP A-NP A-NP A-NP A-NP Radiation Protection Dept. Based 2 2 2 2 2 Student Mentor Updates Dept. Based 2 A A First Aid at Work Taught sessions Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP First Aid at Work Refresher Taught session 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP First Aid one day appointed persons refresher First Aid one day appointed persons Taught sessions Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP Once-NP Taught session 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP 3-NP H&S Risk Assessor Taught session A-NP A-NP A-NP A-NP A-NP A-NP A-NP A-NP A-NP A-NP A-NP A-NP TUG Driver Taught session A A A Medical Devices Local IN- Dept. Based Local IN-N Local IN-N Local IN-N Local IN-N Local IN-N Local IN-N Local IN-N Local IN-N N Local IN-N Medical Gasses Local IN- Dept. Based Local IN-N Local IN-N Local IN-N Local IN-N Local IN-N Local IN-N Local IN-N Local IN-N N Local IN-N Medicines Management Dept. Based Local IN Local IN Local IN Local IN Local IN Local IN Local IN Local IN VTE Prevention e-learning Once Once Once Once Once Once Once Once Bribery Act e-learning IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 IN-3 Non-Clinical Senior Managers Page 7 of 10
Appendix 1 Health Record Keeping For staff involved in clinical record keeping Completion of Information Governance package and annual Information Governance Refresher Local induction and adherence to clinical record keeping policy KEY = relevant to role IN- Induction A=Annual 2=Biennial 3=Every 3 years (P)=Paediatric staff only NP=Nominated Person only Local IN-N = Local Induction and when new equipment is used RA = Risk Assessment if identified for role as result of local risk assessment. Contact Health & Safety team for information * = With direct patient contact responsibilities Infection Control level 1 training includes hand hygiene Induction includes the following: Safeguarding (overview); Health and Safety including slips, trips and falls; incident reporting; inoculation incidents; complaints, Equality and Diversity mandatory session; bullying and harassment/dignity and respect; e-learning modules as per matrix Page 8 of 10
Safeguarding Children Training Requirements and Opportunities Appendix 2 For all staff Level 1 via Trust Induction on appointment and then update via Breeze Presentation every 3 years Which additional training do you need? Do you have frequent and prolonged face to face contact with parent/carers and/or children and young people? E.g: Adult nurses, Adult HCA, Emergency dept reception staff, ward clerks in children s areas, adult physicians. You only require to complete the Level 1 update required every three years via No Yes Level 2 Breeze Presentation (required every 3 years) Online E-learning Level 2 (Foundation) programme contact the Trust Safeguarding Team OR Multiagency face to face Group A Programme No No Is your work predominantly with parent/carers and/or children and young people? E.g.: Paediatric nurses and practitioners, HPS, allied health professionals working directly with children, staff working in emergency dept Yes Do you have clinical contact with children/young people? Yes Level 3 (required every year) Training delivered by Named Nurse for Child Protection & Safeguarding Trainer. OR Online E- Learning Level 3(Core) programme. Contact the Trust Safeguarding Team OR Multiagency face to face Group A/B Programme. OR Accrediting academic lectures or courses. Contact Safeguarding Trainer Page 9 of 10
THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST IMPACT ASSESSMENT SCREENING FORM A This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Policy Title: Mandatory Training Policy Policy Author: Karen Giles, Head of Education and Development Yes/No? You must provide evidence to support your response: 1. Does the policy/guidance affect one group less or more favourably than another on the basis of the following: (* denotes protected characteristics under the Equality Act 2010) Race * NO Required by all staff Ethnic origins (including gypsies and travellers) NO Required by all staff Nationality NO Required by all staff Gender * NO Required by all staff Culture NO Required by all staff Religion or belief * NO Required by all staff Sexual orientation including lesbian, gay and bisexual people * NO Required by all staff Age * NO Required by all staff Disability learning difficulties, physical disability, sensory impairment and mental health problems * YES Gender reassignment * NO Required by all staff Marriage and civil partnership * NO Required by all staff 2. Is there any evidence that some groups are affected differently? NO Required by all staff 3. If you have identified potential discrimination which can include associative 4(a). 4(b). 4(c). 4(d) discrimination i.e. direct discrimination against someone because they associate with another person who possesses a protected characteristic, are any exceptions valid, legal and/or justifiable? Is the impact of the policy/guidance likely to be negative? (If yes, please answer sections 4(b) to 4(d)). If so can the impact be avoided? What alternatives are there to achieving the policy/guidance without the impact? Can we reduce the impact by taking different action? None identified No Training delivery/access would be amended to meet identified sensory or physical impairment as required on an individual basis Comments: Action Plan due (or Not Applicable):N/A Name and Designation of Person responsible for completion of this form: Karen Giles Date: 25.4.12 Names & Designations of those involved in the impact assessment screening process: Employment Policies and Procedures Consultative Group (If any reader of this procedural document identifies a potential discriminatory impact that has not been identified on this form, please refer to the Policy Author identified above, together with any suggestions for the actions required to avoid/reduce this impact.) Page 10 of 10