The purpose of this document is to outline the processes for mandatory training within the Trust.

Trust Policy and Procedure Document ref. no: PP(16)244 Policy and procedure for Mandatory and Statutory training For use in: For use by: For use for: Document owner: Status: Trust Wide All staff and temporary workers employed by the Trust except Doctors in training Mandatory Training Deputy Director of Workforce (Development) Approved 1. Table of Contents 1. Table of Contents... 1 2. Purpose of document... 1 3. Introduction... 1 4. Scope... 2 5. Definitions and abbreviations... 2 6. Objectives... 3 7. Recording, reporting and monitoring of mandatory training... 3 7.1 Mandatory Training Report follow up process... 4 8. Roles and responsibilities... 4 8.1 Trust Board... 4 8.2 Committee responsibilities... 5 8.3 Corporate lead... 5 8.4 Managers... 6 8.5 Mandatory Trainers/ Facilitators/Subject Matter Experts... 6 8.6 All staff and temporary workers... 7 9. Monitoring... 7 10. Review... 8 11. Document Configuration... 8 Appendix A: High Level Mandatory Training Matrix (Extract)... 9 Appendix B: Mandatory Training Subject Anaysis... 10 Appendix C: Mandatory Training Directorate Performance Report (Extract)... 11 Appendix D: Mandatory Training Report (Extract)... 12 2. Purpose of document The purpose of this document is to outline the processes for mandatory training within the Trust. 3. Introduction The West Suffolk Hospital NHS Foundation Trust aims to provide the highest quality care to all patients using its services. In order to minimise risk to both patients and staff, all staff and temporary workers are required to complete mandatory training to deliver safe effective service in their area of work. The Trust is committed to ensuring that adequate provision is made for mandatory training and for staff to be released to undertake such training. Source: Deputy Director of Workforce (Development) Status: Approved Page 1 of 12

4. Scope The policy applies to all staff and temporary workers who are employed by the Trust except Doctors in training. This includes permanent staff, fixed term contracts and temporary staff including West Suffolk Professionals and honorary contracts. Temporary workers employed via agencies and contractors must sign a declaration to confirm they have read and understood the relevant training workbook before they start work for the Trust, this includes local fire procedures. For medical staff this will form part of the Locum Handbook. This policy specifically excludes doctors in training who are covered by the separate Trust Policy PP160 Junior Doctors Induction and as placements are less than 12 months, do not have ongoing corporate mandatory training needs outside induction. This policy sets out a framework for ensuring that staff and temporary workers receive corporate mandatory training according to risk assessment as per the Mandatory Training Matrix (see Appendix A). This matrix is available on the Trust intranet. This policy must be read in conjunction with the Trust Induction policy PP076. 5. Definitions and abbreviations Staff This includes all employees that are employed on a permanent and fixed term contract Temporary Workers This includes employees on bank only contracts Mandatory training For the purposes of this policy; mandatory training is any statutory or compulsory training that the Trust requires its employees to undertake: To comply with the law and requirements of regulatory bodies To carry out duties safely and efficiently To maintain competence to the required standards Mandatory Training Matrix The mandatory training matrix identifies the required training by staff group and role and the frequency of updates required for each type of training. These include taught sessions / programmes, E-learning and training workbooks. Training Needs Analysis is an assessment of the resource requirements to undertake the training outlined in the Mandatory Training Matrix. This will consider the resources required to deliver training and to release staff to undertake training. Additional mandatory specialist training Some mandatory training is specific to particular staff groups, disciplines or roles (e.g. Corgi registration for electricians, CTG training for midwives) this is identified as second level training. QRC Quality & Risk Committee PDP Additional training may be determined locally by managers as part of the Personal Development Plan/ Appraisal process (e.g. word processing). TEG Trust Executive Group Source: Deputy Director of Workforce (Development) Status: Approved Page 2 of 12

CRC ESC ESR OLM Corporate Risk Committee Education Strategy Committee Electronic Staff Record Oracle Learning Manager NHSLA NHS Litigation Authority MTSG Mandatory Training Steering Group CSTF Core Skills Training Framework WSP West Suffolk Professionals 6. Objectives To systematically define mandatory training requirements for all staff groups To provide clarity around roles and responsibilities to deliver these requirements and maintain accurate records To provide a process to ensure systematic uptake of the defined mandatory training for all staff groups. To provide a process for monitoring compliance with this policy 7. Recording, reporting and monitoring of mandatory training Accurate recording of mandatory training records are essential as it provides evidence of compliance required by internal and external assessors, as well as cases of liability/negligence brought against the organisation. All staff and temporary workers attending mandatory training events must ensure that their attendance is recorded accurately by signing the attendance record. Staff and temporary workers attendance at corporate mandatory training events is recorded by the education provider or a nominated learning administrator on the Trusts learning management system OLM (a module of ESR). Completion of e-learning mandatory training is automatically uploaded onto OLM. Completion of training workbooks is recorded by West Suffolk Professionals, Medical Staffing or the Education Team on OLM, dependant on job role. Archives of training records and course content are maintained within the system. The Trust Board receive a quarterly Mandatory Training Subject Analysis report showing staff s compliance by subject area (see Appendix B) A monthly Directorate Performance Report is produced showing staff s take up of mandatory training by directorate/subject. This report is provided to the Trusts Compliance Manager, all Subject Matter Experts and Directorate General Managers. (See Appendix C) Source: Deputy Director of Workforce (Development) Status: Approved Page 3 of 12

A monthly Mandatory Training Report detailing whether staff meet, do not meet or are due to expire mandatory requirement by subject, is provided to Budget Holders/Managers/Clinical Directors. A monthly Mandatory Training Report detailing whether temporary workers meet, do not meet or are due to expire mandatory requirement by subject, is provided to the Medical Staffing HR Assistant and West Suffolk Professionals. Non-compliant staff will be followed up by the relevant team. Both reports are updated each month and are available to all staff on O:\Mandatory Training Reports. 7.1 Mandatory Training Report follow up process The Trust Board have tasked managers and employees to reach required compliance with all areas of mandatory training. A reminder email is sent out every month and the Mandatory Training report is available on the O drive every month (from 10 th of each month). For temporary workers the report is followed up by the relevant team, either Medical Staffing or WSP. Compliance for staff is reported monthly to Directorate Performance meetings and quarterly to the Board of Directors. Any temporary worker who is identified as being non-compliant with their mandatory training requirements for 3 consecutive months will have restrictions placed, preventing them from working further shifts until they complete the required training. All managers are required to: 1. Identify staff who need to update their mandatory training. 2. Communicate to all those staff who do not meet their requirements for mandatory training, informing of the need to complete the necessary training. 3. This process should be followed up within 31 days for e-learning and within a reasonable time frame for face to face training. Failure of staff to comply with the manager s request within the timeframe may lead to formal action. You can access the Mandatory Training Report for each month from the following location: O:\Mandatory Training Reports 8 Roles and responsibilities 8.1 Trust Board The Trust has a duty to its staff, temporary workers, patients and visitors to ensure that: Appropriate mandatory training is provided for all staff that meets the needs of their role. This applies to staff employed whole, part time, bank or engaged in a regular voluntary capacity. All staff and temporary workers attend mandatory training sessions at the required time intervals, or are released to undertake e- learning or a training workbook. Accurate records are kept of all mandatory training undertaken. A process is in place to follow up those who fail to attend mandatory training. A process is in place to follow up those that are overdue their mandatory training. Source: Deputy Director of Workforce (Development) Status: Approved Page 4 of 12

This responsibility is delegated to the Board subcommittee the CRC. The Q&RC will ensure these responsibilities are enacted as part of its role in reviewing the activities of these committees. The Trust Board will review mandatory training compliance on a quarterly basis by reference to the Mandatory Training Board Report. 8.2 Committee responsibilities The ESC will receive updates on any changes in the delivery mode or content of mandatory training and mandatory training activity. As part of this remit the committee will provide a six monthly performance report on corporate mandatory training to the CRC. The individual directorate performance meetings will receive monthly Directorate Performance Reports on corporate mandatory training and take action to address gaps in uptake. MTSG will provide clear definition of the content of mandatory training, maintain robust arrangements to ensure effective and efficient delivery, monitor compliance and ensure that a system is in place to record and report on compliance. They will also agree on any changes to the mandatory training matrix including the identification of the leads/subject matter experts for any additional subjects. The identified lead/subject matter expert will be responsible for determining which staff and temporary workers are required to complete the training and what the most appropriate delivery option should be. The OLM/Mandatory training co-ordinator will report any agreed changes of the mandatory training matrix to the Workforce Education Team who will update the prospectus annually. 8.3 Corporate lead The Deputy Director of Workforce (Development) will have overall responsibility for coordination and implementation of this policy.this responsibility includes: Ensuring staff and temporary workers are aware of the availability of mandatory training via the OLM learning management system and the up to date Education & Training Prospectus (available on the intranet). Co-ordination and administration of the delivery of corporate mandatory training to include clearly defined booking and cancellation processes. Ensuring a process is in place for following up non-attendance by informing the individual s manager of their non-attendance and their responsibility in advising staff and temporary workers of the need to re-book. (Non-attendance policy PP270) Review and annual update of corporate mandatory training provision and the Education & Training Prospectus to ensure they meet both Trust and national requirements. Develop an annual Training Needs Analysis to quantify the resource requirements of implementing the Training Matrix for Corporate Mandatory training Developing, recording and reporting processes via ESR/OLM to enable monitoring of compliance with corporate mandatory training. Source: Deputy Director of Workforce (Development) Status: Approved Page 5 of 12

Provide quarterly performance reports to the ESC, Directorate Performance Meetings and six monthly CRC on corporate mandatory training 8.4 Managers It is the responsibility of all managers to: Ensure that all their staff are aware of the need to comply with mandatory training according to role requirements. Review the monthly Mandatory Training report to ensure all staff are compliant in their role requirements. Ensure that all their staff and temporary workers, whether employed whole, parttime, bank or engaged in regular voluntary capacity, have attended and are up to date with the relevant mandatory training for their role prior to attending any other training. Managers should also ensure that staff and temporary workers who have not completed their required mandatory training should not be given permission to attend other developmental activities/training until such time as their mandatory training is compliant. Plan for their staff to complete the relevant mandatory training and give protected time for this. Identify and provide any mandatory training that is required for their area of responsibility/staff members and that is not included in the corporate programme and ensure that this is recorded. Ensure that during the annual staff appraisal they:- o Check compliance with mandatory training o Check required competencies o Identify learning needs and refresher requirements Follow the steps outlined in the Mandatory Training report follow up process (see 7.1 above) to ensure all non compliant staff enrol and complete mandatory training. It is recognised that there will be occasions when staff and temporary workers may not be able to attend some or all of the corporate mandatory training due to disability or unavoidable domestic or other commitments. In these instances the manager in consultation with the education provider must make alternative arrangements to ensure that these staff are able to complete the mandatory training requirements for their post. 8.5 Mandatory Trainers/ Facilitators/Subject Matter Experts (SME) It is the responsibility of mandatory trainers/facilitators/sme to: Plan, deliver, evaluate and continually improve training sessions/programmes ensuring they are evidence based and for the 11 subjects where it is appropriate, meet the Core Skills Training Framework learning outcomes Maintain and archive records of content, duration and method of delivery of training Ensure that participants record their attendance at sessions/programmes using the sign in sheet and maintain a five year archive of these documents Source: Deputy Director of Workforce (Development) Status: Approved Page 6 of 12

Update the trust mandatory training learning management system OLM with records of attendance in good time to allow for reporting at the beginning of each month. Ensure participants complete an evaluation form at the end of sessions/programmes. Review the monthly Directorate Performance Report to identify any areas where their subject is falling below the targets laid out by the Trust Contribute to the evaluation, review and development of mandatory training as required. 8.6 All staff and temporary workers It is the responsibility of all staff, whether employed whole, part- time, bank or engaged in regular voluntary to: Ensure their corporate mandatory training requirements, as identified on their mandatory training matrix, accessed via the e-learning system are kept up to date. Give priority to mandatory training and make every effort to undertake training sessions arranged for this purpose. Staff alert their line manager and the provider of the training if they are unable to attend. Temporary workers alert either WSP or Medical Staffing HR Assistant dependant on job role and the provider of the training if they are unable to attend. Sign the attendance record for all classroom sessions/programmes. Ensure all elearning courses are confirmed as COMPLETED before moving to Learning History Where access to e-learning is not possible, ensure the relevant training workbook is completed and the test and declaration is returned to the appropriate department to be recorded on OLM. Complete the evaluation for the session/programme. Review the record of their mandatory training via their compliance matrix which is accessed through the elearning system, their line manager, or the Mandatory Training monthly report for the purposes of o ensuring accuracy o identifying when updating is required o informing the appraisal process Apply the learning and techniques to their area of work/role. 9 Monitoring Implementation, compliance and effectiveness of this policy will be monitored by the ESC on an annual basis. Source: Deputy Director of Workforce (Development) Status: Approved Page 7 of 12

This will be achieved through a combination of reports on uptake of training, appropriate archiving of training processes, records maintenance, DNA rates, publication of annual prospectus and elearning, changes to matrix driven by internal and external factors and development of an annual TNA based on the training matrix. 10 Review This policy will be reviewed on a 3 yearly basis. The timing of the review will be coordinated with the issue of the Education & Training Prospectus and e-learning packages. Earlier review may be required in response to exceptional circumstances, organisational change or relevant changes in legislation or guidance. 11 Document Configuration Author(s): Deputy Director of Workforce (Development) & OLM/Mandatory Training Co-ordinator. Other contributors: Trust Secretary & Head of Governance, Compliance Manager, Members of MTSG. Approvals and endorsements: Mandatory Training Steering Group Consultation: Education Strategy Committee Issue no: 7 File name: PP(16)244 Mandatory training policy Supersedes: PP(14)244 Equality Assessed Yes Implementation Through named individuals and responsibilities as set out in the policy Monitoring: See section 7 Other relevant policies/documents & references: PP184 Appraisal, Personal Development Planning And KSF Policy, PP076 Induction Management Guidelines, PP160 - Junior Doctors Induction PP270 Nonattendance Policy, PP067 Study Leave Policy Additional Information: We welcome feedback on this policy and the way it operates. We are interested to know of any possible or actual adverse impact that this policy may have on any group in respect of gender or marital status, race, disability, sexual orientation, religion or belief, age or any other characteristics. The person responsible for equality impact assessment for this policy is the Deputy Director of Workforce (Development)) This policy has been screened to determine equality relevance. This policy is considered to have little or no equality relevance. Source: Deputy Director of Workforce (Development) Status: Approved Page 8 of 12

Registered nurses Nursing assistants Midwives MCAs Medical staff (senior / permanent) Medical staff (in training) Physiotherapists Occupational Therapists Pharmacists Pathology Consultants/Nurses Pathology Staff Orthoptists Dietetics Diagnostic Radiographers Cardiac physiologists Cardiac assistants Audiologists Theatre practitioners Admin & clerical / Managerial Chaplains Estates & Facilities Ancillary staff Estates & Facilities Administrative staff Speech & Language Therapists Appendix A: High Level Mandatory Training Matrix (Extract) Trust Corporate Mandatory Training Matrix Frequency Refresher update Format Staff group ESR Competency Name 1 Corporate (Trust) Induction All staff (apart Once Only from NA's) 179 Trust Induction Face to Face 2 Moving and handling 3a Clinical Annual 179 Moving and Handling - Clinical 3b Non Clinical - Load handler Specific staff Annual 179 Moving and Handling - Non Clinical Load Handler 3 Fire safety 4 Basic Life Support 5a Adult 5 6 Violence & aggression / conflict resolution Infection prevention & control / Hand hygiene 7 Safeguarding Children 3c elearning Bi Annual E-learning 179 Moving & Handling - elearning 4a Fire safety (ftf) 2 yearly Face to Face 179 Fire Safety - Classroom All staff 4b Fire safety (e) Annual E-learning 179 Fire Safety - elearning Clinical staff only Annual Face to face 179 Basic Life Support - Adult 6a Classroom Specific staff 3 yearly Face to face *3 *3 *1 *1 *1 179 Conflict Resolution 6b elearning Specific staff 3 yearly E-learning *3 *3 179 Conflict Resolution - elearning 7a Nursing 3 yearly Face to Face 179 Infection Control - Classroom Specific Staff 7b Others 3 yearly E-Learning 179 Infection Control - elearning 8a Level 1 All staff 3 yearly E-Learning NHS MAND Safeguarding Children Level 1-3 Year 8b Level 2 Specific staff 3 yearly E-Learning *2 *2 179 Safeguarding Children Level 2 8c Level 3 Specific staff Annual Face to Face *4 *4 *4 *4 *4 NHS MAND Safeguarding Children Level 3-1 Year 8 Safeguarding Adults (including Prevent aw areness) 3 yearly 179 Safeguarding Adults & 179 LOCAL PREVENT Aw areness 9 Health & Safety 3 yearly 179 Health & Safety / Risk Management 10 Information Governance Annual 179 Information Governance All Staff 11 Emergency Preparedness (Majax) 3 yearly 179 Majax 12 Equality & Diversity 3 yearly 179 Equality & Diversity E-learning 13 Security Aw areness 3 yearly 179 Security Aw areness 14 Blood products & transfusion processes Annual *2 *2 *2 *2 *2 *2 *2 179 Blood products & transfusion processes (Refresher) 15 Slips, Trips and Falls (patient) 3 yearly 179 Slips Trips Falls Clinical staff only 16 Medicine management 3 yearly 179 Medicine Management (Refresher) 17 Exposure to blood-borne viruses / Inoculation incidents 3 yearly 179 Blood Bourne Viruses/Inoculation Incidents 18 PREVENT WRAP Once only 179 LOCAL PREVENT WRAP (Workshop to Raise Aw areness of Clinical staff only Face to Face Prevent) NOTES: *1 Those who are in a role where they are frequently in contact with members of *2 Identified specialities only *3 Identified specialities only *4 High contact areas only Source: Deputy Director of Workforce (Development) Status: Approved Page 9 of 12

Trust Target Does not meet requirement Meets Requirement Grand Total Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Appendix B: Mandatory Training Subject Analysis Competence Name 179 LOCAL Infection Control - Classroom 80% 105 1415 1520 95.09% 93.86% 94.46% 92.98% 91.22% 93.09% 179 LOCAL Safeguarding Children Level 2 90% 109 1437 1546 91.43% 91.95% 92.51% 92.10% 91.25% 92.95% NHS MAND Safeguarding Children Level 3-1 Year 90% 22 287 309 87.70% 89.62% 88.75% 88.01% 91.40% 92.88% 179 LOCAL Security Awareness 80% 228 2923 3151 91.08% 92.17% 92.69% 92.62% 91.75% 92.76% NHS MAND Safeguarding Children Level 1-3 Years 90% 250 2901 3151 90.28% 91.21% 91.64% 91.10% 90.45% 92.07% 179 LOCAL Infection Control - elearning 80% 137 1337 1474 86.98% 89.70% 89.74% 89.37% 89.78% 90.71% 179 LOCAL Safeguarding Adults 80% 294 2857 3151 89.71% 90.89% 90.68% 89.96% 89.50% 90.67% 179 LOCAL Information Governance 95% 325 2826 3151 85.50% 85.25% 84.39% 82.98% 85.91% 89.69% 179 LOCAL Fire Safety Training - Classroom 80% 330 2821 3151 86.65% 86.69% 87.12% 87.45% 87.06% 89.53% 179 LOCAL MAJAX 80% 333 2818 3151 88.11% 89.46% 89.44% 89.26% 88.64% 89.43% 179 LOCAL Health & Safety / Risk Management 80% 335 2816 3151 89.26% 89.84% 89.73% 88.43% 88.36% 89.37% 179 LOCAL Slips Trips Falls 80% 234 1874 2108 88.47% 88.97% 89.90% 88.81% 87.68% 88.90% 179 LOCAL Medicine Management (Refresher) 80% 173 1310 1483 88.45% 90.06% 89.85% 88.58% 87.88% 88.33% 179 LOCAL Fire Safety Training - elearning 80% 375 2776 3151 82.89% 84.39% 84.45% 85.55% 85.88% 88.10% 179 LOCAL Blood Bourne Viruses/Inoculation Incidents 80% 231 1683 1914 87.82% 88.91% 89.01% 88.28% 87.78% 87.93% 179 LOCAL Equality and Diversity 80% 428 2723 3151 75.33% 79.49% 81.65% 82.54% 83.60% 86.42% 179 LOCAL Moving and Handling Non Clinical Load Handler 80% 61 299 360 78.42% 81.20% 83.42% 85.14% 81.27% 83.06% 179 LOCAL Moving and Handling - Clinical 80% 291 1422 1713 82.41% 83.55% 84.91% 83.74% 82.90% 83.01% 179 LOCAL Blood Products & Transfusion Processes (Refresher) 80% 297 1273 1570 81.53% 80.54% 82.08% 81.73% 80.71% 81.08% 179 LOCAL Basic Life Support - Adult 80% 405 1664 2069 80.35% 81.90% 81.73% 81.26% 79.69% 80.43% 179 LOCAL Conflict Resolution 80% 252 971 1223 79.10% 77.51% 78.56% 80.41% 79.47% 79.39% 179 LOCAL Moving & Handling - elearning 80% 214 745 959 74.71% 76.50% 74.09% 75.10% 76.94% 77.69% 179 LOCAL Conflict Resolution - elearning 80% 175 556 731 75.69% 78.04% 76.02% 75.34% 74.21% 76.06% Source: Deputy Director of Workforce (Development) Status: Approved Page 10 of 12

Appendix C: Mandatory Training Directorate Performance Report (Extract) Directorate Competence Name Does not meet requirement Meets Requirement Grand Total % that Fulfil Competence Requirements Movement on last month +/- 179 Clinical Support Directorate 179 LOCAL Basic Life Support - Adult 83 252 335 75.22% -1.28% 179 LOCAL Blood Bourne Viruses/Inoculation Incidents 25 166 191 86.91% -0.92% 179 LOCAL Blood Products & Transfusion Processes (Refresher) 8 29 37 78.38% -2.70% 179 LOCAL Conflict Resolution - elearning 24 135 159 84.91% -1.89% 179 LOCAL Conflict Resolution 34 116 150 77.33% -1.72% 179 LOCAL Fire Safety Training - Classroom 99 422 521 81.00% -2.27% 179 LOCAL Fire Safety Training - elearning 69 452 521 86.76% -1.71% 179 LOCAL Health & Safety / Risk Management 34 487 521 93.47% 1.17% 179 LOCAL Infection Control - Classroom 2 75 77 97.40% 1.35% 179 LOCAL Infection Control - elearning 22 372 394 94.42% 0.00% 179 LOCAL Information Governance 59 462 521 88.68% 0.41% 179 LOCAL MAJAX 46 475 521 91.17% 0.21% 179 LOCAL Medicine Management (Refresher) 18 177 195 90.77% -1.03% 179 LOCAL Moving & Handling - elearning 8 137 145 94.48% 0.69% 179 LOCAL Moving and Handling - Clinical 99 191 290 65.86% -6.61% 179 LOCAL Moving and Handling Non Clinical Load Handler 4 70 74 94.59% 7.75% 179 LOCAL Safeguarding Children Level 2 12 175 187 93.58% -1.55% 179 LOCAL Security Awareness 31 490 521 94.05% 0.97% 179 LOCAL Slips Trips Falls 39 291 330 88.18% -1.11% 179 LOCAL Vulnerable Adults 41 480 521 92.13% 0.59% NHS MAND Safeguarding Children Level 1-3 Years 40 481 521 92.32% 0.78% NHS MAND Safeguarding Children Level 3-1 Year 2 2 4 50.00% -25.00% Source: Deputy Director of Workforce (Development) Status: Approved Page 11 of 12

Appendix D: Mandatory Training Report (Extract) *Fictitious staff names and data have been used for this example Source: Deputy Director of Workforce (Development) Status: Approved Page 12 of 12