/Policies and guidelines/Statutory and mandatory training policy

Statutory and mandatory training policy

Document control

Policy owner: Organisational development lead
Corporate lead: Director of workforce, OD and system development
Document version: V1
Date approved by Joint Negotiating Consultative Forum(JNCF): September 2024
Date ratified by Trust Leadership team: September 2024
Date issued: February 2025
Next review date: December 2029

Executive summary

This policy sets out Leeds Community Healthcare (LCH) NHS Trust’s statutory and mandatory training requirements in line with trust objectives, legislative requirements and the requirements of the core skills training framework(CSTF). This Framework sets out the national standard for statutory and mandatory training requirements and is critical to ensuring transfer of staff between NHS organisations via a digital passport.

This policy covers all Staff employed by the trust and extends to bank staff, volunteers and secondees into the trust, honorary contract holders, agency and contingency workforce. The specific roles and responsibilities for implementation and monitoring of this Policy are also identified.

The statutory and mandatory training needs analysis (TNA) will be updated as a minimum annually to ensure the Trust is complying with changes in legislation. The policy will be reviewed annually.

Table of content

Introduction
Aims and objectives
Definitions
Responsibilities
Statutory and mandatory training for staff not employed by the trust placements
Review and management of statutory and mandatory training
Monitoring compliance and effectiveness
Recording and reporting process
Ratification and approval process
Dissemination and implementation
Review arrangements
Equality analysis
Associated documents
References
Appendices

1. Introduction

This policy incorporates the training areas which the trust regards as statutory or mandatory for all staff to undertake, dependent upon their role. The scope does not extend to specific professional or local training, however, is intended to provide clarity in the requirements for the core statutory and mandatory provision, in order to fulfil the responsibility of the trust as an employer, and the responsibility of individual staff members, to meet legal, professional or national standards. It also clarifies roles and responsibilities for Policy implementation. The trust has set the current compliance target for statutory and mandatory training as 95%.

The trust supports the government’s philosophy that lifelong learning and development are key to delivering the NHS vision of patient-centred care. As such the trust is committed to equipping staff with the necessary skills required to undertake their roles competently and confidently. In turn, staff must take responsibility for developing these skills and participating in the lifelong learning process.

The policy must be read in the context of the individual job role and ensure that staff are familiar with their work environment, policies, and procedures and issues pertinent to their local place of work. It is the responsibility of line managers to ensure that training competency requirements for roles are appropriately specified for all members of staff under their management. To ensure this policy is viewed in context it must be read in conjunction with the induction policy available on the trust intranet.

The corporate and local induction process within the trust is designed to focus managers and staff on core statutory and mandatory training. All managers must ensure that all newly appointed staff (and existing staff that move into a new role within the organisation), are immediately assessed to determine what training is relevant to their job role. All statutory
and mandatory training identified must be completed within 3 months of appointment. This policy also provides clarification on the mandatory requirements for temporary, seconded, bank, agency and contingency workforce.

2. Aims and objectives

The policy sets out Leeds Community Healthcare (LCH) NHS Trust’s statutory and mandatory training requirements in line with trust objectives, legislative requirements and the requirements of the CSTF (core skills training framework). This policy has been developed in consultation with staff side and management side representatives, and other key stakeholders. This policy is to be read by all staff to understand their responsibilities around statutory and mandatory training requirements. To ensure that the trust is compliant with any new legislation, changes to training programmes will continue to be made throughout the year, with the policy being reviewed on an annual basis. Any changes will be cascaded using the communication methods available within the trust.

3. Definitions of training and terms

Statutory is training that is laid down by law, primarily in section 2 of the Health and Safety at Work Act (1974).

Mandatory is training that the trust itself recognises as essential for someone to safely undertake a task or role, or to comply with other trust policies or strategies, for example, for the development of the organisation.

All staff employed includes those on permanent or temporary contracts, (includes chief executive, executive and non executive directors and Senior Management team), full-time, part-time and provisions of this policy extends to bank staff, volunteers and into the trust.

Agency, secondees, contingency workforce and honorary contract holders are identified as staff not employed by the trust.

Clinical staff (Hands on): Registered and non-registered staff working in a clinical role providing direct clinical care, for example, district nursing, Intermediate care, prison service, children’s nursing, physiotherapists, occupational therapists.

Clinical staff (Hands off): Registered and non-registered staff who provide clinical care but do not directly handle patients, for example, health visiting, CAMHS, dietitians.

Non-clinical staff (Patient facing): Staff working in roles where they will come into direct contact with patients and the public, for example, health centre receptions, Leeds Equipment Services, domestics.

Non-clinical staff (Non-patient facing): Staff working in roles where there is no direct patient, for example, finance, workforce, office based administrators.

Training needs analysis (TNA): For the purpose of this policy, TNA relates to all statutory and mandatory training agreed through the process identified in this policy.

4. Responsibilities

Chief executive and trust board are responsible for:

ensuring that the statutory and mandatory training policy (including training needs analysis) is in place and that all staff working in the trust are aware of, comply with and operate within the policy.
attending the board induction or development programme.
the performance management of this policy.

Executive directors and Senior Management team will:

ensure that this policy is implemented within their sphere of responsibility
attend the board induction or development programme
manage non compliance for this policy through the Business Committee reports
proactively manage areas of concern highlighted with general managers.

Director of workforce will:

on behalf of the chief executive, ensure the implementation of this policy throughout the trust and evaluate its effectiveness on an annual basis, ensuring it is up-to-date and making necessary changes
inform the relevant Workforce teams of any issues which may change needs for statutory and mandatory training provision
lead the process for ratifying new or amended policies or procedures in this respect.

The Business Committee will:

review monthly reports from Workforce Information and seek assurances that statutory and mandatory training for staff are meeting the expected delivery rates versus actual including non-attendance data
where issues are identified, advise, recommend and monitor improvements
receive monthly reporting to monitor compliance on a monthly basis.

The Organisational Development and Improvement (ODI) team will:

work with services and subject matter experts to establish appropriate levels of training for specific roles
ensure training provision is commissioned to meet the main requirements of this policy, to the standard required
support business units and Corporate teams in the monitoring of their compliance and if necessary take appropriate corrective action
ensure systems and processes are in place for all staff to access statutory and mandatory training
liaise with all stakeholders to ensure effective operation of the overall system
ensure clear processes are in place for statutory and mandatory training, known and available to key stakeholders
monitor and report on achievement against compliance targets
seek assurance around quality assurance evaluation from SME
provide administrative support for some courses.

Subject matter experts (SME) will:

define the training requirements in line with the CSTF (core skills training framework)
liaise with all relevant stakeholders to agree which roles require what types of training
have a clear understanding of CSTF framework and ensure that all statutory and mandatory training provided meets CSTF requirements
ensure all training has clear aims, objectives and delivery methods which may include the provision of alternative delivery format to meet the needs of individuals, for example, providing signers or audio versions at training sessions
ensure ongoing monitoring of training compliance
evaluate training to ensure consistent quality.

The Workforce Information team will:

produce quarterly and monthly reports to the Business Committee on statutory and mandatory training compliance, including non-attendance
using the electronic staff record (ESR), maintain records of attendance and provide information in the agreed format
advertise training provision using the course catalogue
identify and monitor training compliance and share this information with relevant stakeholders and subject matter experts
provide support to staff in terms of accessing training and recording compliance.

All managers will:

ensure that training competency requirements for roles are appropriately specified for all employees under their line management
ensure employees attend all relevant training, including updates, at the required frequency. For staff not employed by the trust refer to section 5
enable employees to attend training on which they are booked, for the required duration
ensure that they follow up non-attendance with the member of staff
escalate areas of risk in relation to statutory and mandatory training to the Senior Management team (SMT)
support individuals through the appraisal process ensuring they attend statutory and mandatory training relevant to role. Provide relevant resources to enable employees to transfer learning from the training into everyday practice.
liaise with ODI and subject matter experts to arrange training they regard as necessary to meet specific local criteria or circumstances
using ESR, check staff compliance regularly
report any issues associated with training access or delivery to subject matter experts, workforce information or organisational development and improvement.

Employees have a responsibility to:

source appropriate training via ESR and book on to training
attend all relevant statutory and mandatory training
attend the session on which they are booked
report any issues associated with training access or delivery to SME, WFI or ODI
inform their line manager and Workforce Information when unable to attend a booked session and cancel their booked place on ESR
attend session at the next available opportunity if failed to attend the initial session
ensure that workforce information and course leads are aware of any dietary, access or specific requirements
keep up-to-date with relevant LCH policies
where job specific, maintain professional accountability, registration and operate within their scope of professional practice
through 1 to 1’s and appraisal, plan and review training with their appraisers complete the relevant attendance documentation.

5. Statutory and mandatory training for staff not employed by the trust placements

5.1 Healthcare students

Under the Learning and Development Agreement it is agreed that Universities will provide statutory and mandatory training required by pre-registration students. The type of training and content is agreed in partnership with healthcare provider organisations. The exception to this is those undertaking an apprenticeship programme where their employer will provide
training as they remain an employee of LCH and their training needs will be included under the statutory and mandatory provision and reporting as for all staff.

Those undertaking post-registration courses and on placement within LCH will normally be our own employees and will be covered under the relevant section of this policy. Any post registration student not employed by us will be issued an honorary contract and their statutory and mandatory training provision will be covered under that section of this policy.

In all cases the induction into the workplace received by the student will cover relevant issues specific to that area, for example, fire procedures. This is included in the student’s placement profile and is therefore monitored through the university quality assurance processes.

5.2 Students subsequently employed

Mandatory training that is undertaken at University that is valid and current (for example, in date) may be considered as accredited prior learning (APL) if appropriate.

5.3 Volunteers

Volunteers must also receive adequate training to carry out their roles. Training needs must be assessed at interview and during induction, by the person responsible for managing their involvement with the Trust. For more information please refer to the updated training needs analysis grid on the intranet).
<h35.4 Agency, contingent workforce, honorary contract holders and placements

Managers recruiting agency, secondees, contingent workforce, honorary contract holders and placements must ensure that these staff members have the required Statutory and Mandatory training to perform their role.

5.5 Secondees

Secondees must ensure they maintain training compliance with their host or employing organisation.

5.6 Bank staff

Bank staff must receive statutory and mandatory training relevant to the role they will be undertaking. Other training undertaken will be assessed via the learning outcomes achieved, at recruitment stage.

6. Review, management of statutory and mandatory training

Statutory and Mandatory training for the Organisation is determined by legislation, external
bodies including NHSLA, CQC, the Core Skills Training Framework (CSTF) and
Organisational risk.
Ongoing review and management of statutory and mandatory training will be overseen by a
Statutory and Mandatory Training Delivery Group which is chaired by the Workforce Lead
for Statutory and Mandatory training. The group will include Subject Matter Experts for all
training areas, representatives from Workforce Information, and from Business Units. This
group will ensure the following:

identify the demand for training (numbers of staff)
ensure the provision of training in line with demand, service user requirements and compliance with CSTF
review organisational training needs
review and monitor training compliance
identify risk areas and plan actions for improvement
ensure ongoing improvement work to deliver a high quality and responsive training offer
ensure planning of training for the forthcoming year is in place
evaluate training to ensure consistent quality

The group will report any key risks or issues to Business Committee via the monthly well-led report.

To ensure that the trust is compliant with new legislation, changes to overall programme of training will be amended via the Senior Management team. On agreement of changes, the TNA and course catalogue will be updated and the appropriate people affected will be informed of the new requirement via the Trust’s agreed communication methods. Additional training will be commissioned as required.

7. Monitoring compliance and effectiveness

Workforce information will:

collate monitoring of attendance for identified statutory and mandatory training
provide reports on compliance against the organisational target. This information will be monitored and reported to the Business Committee monthly. Business Units will be expected to access compliance information via PIP.

All managers will:

follow up actions and where appropriate highlight any concerns through the risk register
ensure that they are aware of DNAs and ensure that this is being acted upon.

Organisational development will:

work with subject matter experts to monitor course evaluation to inform any training changes
on receiving the information from Workforce Information team, will monitor compliance and work with managers to identify solutions to meet targets.

Compliance will be supported by all parties recognised in this policy undertaking their identified responsibilities.

8. Recording and reporting process

The process for recording and reporting compliance is detailed in appendix A.

9. Ratification and approval process

This policy will be consulted on by subject matter experts, general managers, staff side and approved by the Joint Negotiating Consultative Forum (JNCF) and ratified by the Remuneration Committee on behalf of the board.

10. Dissemination and implementation

ODI are responsible for the dissemination of this policy through the trust intranet and Community Talk.

E-learning should be utilised as a flexible alternative to face-to-face learning wherever possible via the trust e-learning platform. The Workforce Information team will provide advice and guidance to staff that require assistance with e-learning.

The ODI team will facilitate the provision of training within departments and bases by internal trainers and by commissioning external providers to deliver training locally through service level agreements. These training opportunities will be advertised via Community Talk and placed on the intranet.

The trust has determined that all employees must ensure statutory and mandatory training is regarded as a priority. Non-attendance will result in other personal and professional training not being agreed until full compliance is achieved. It is acknowledged that medical staff will ensure statutory and mandatory training is prioritised alongside their wider medical training requirements within the agreed protected learning time framework. Failure to comply with the expectations of this policy could result in further action being taken by the trust.

11. Review arrangements

This policy will be reviewed by the Workforce directorate annually.

12. Equality analysis

LCH aims to design and implement services, policies and measures that meet the diverse needs of its population and workforce, ensuring none are placed at a disadvantage over others.

LCH is subject to the equality duty as set out in the Equality Act 2010 and must pay “due regard” for the need to:

eliminate unlawful discrimination, harassment and victimisation

advance equality of opportunity and foster good relations between people who share a protected characteristic and those who do not

Due regard for advancing equality involves:

removing or minimising disadvantages suffered by people due to their protected characteristics

taking steps to meet the needs of people from protected groups where these are different from the needs of other people

13. Associated documents

LCH induction policy
LCH personal and professional development policy

14. References

Up to date legislation and guidance relevant to this Policy can be found on the statutory and mandatory training needs analysis (TNA). The TNA will be updated as necessary due to changes in legislation or organisational need and this amended TNA will then be uploaded onto the trust’s intranet site.

15. Appendices

15.1 Appendix 1 Flowchart to monitor compliance

Workforce information will receive the signing in sheets from all statutory and mandatory training. If not received, workforce information will email trainers chasing up any outstanding signing in sheets
Workforce Information will update the enrolment status from confirmed to completed on ESR
Business committee and trust board receive regular reports on the performance against target for statutory and mandatory training performance areas. Bank and agency staff are to be included in reporting.
Senior operations performance panel receive monthly updates on all of the statutory and mandatory training areas by business unit, operations and corporate teams. Issues from this forum are escalated to SMT.