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POLICY FOR INDUCTION AND MANDATORY TRAINING

START DATE: August 2013 NEXT REVIEW:

August 2015

COMMITTEE APPROVAL:

Trust Executive Quality Committee

CHAIR’S SIGNATURE:

DATE: Sept 2013

ENDORSED BY: Mandatory Training Committee

DATE: 29th August 2013

DISTRIBUTION: Trust-wide

LOCATION: Intranet: Trust Policies and Procedures

RELATED DOCUMENTS:

Appraisal Policy, Recruitment and Selection Policy, Policy for the Acquisition, Use and Maintenance of and Training for Medical Devices and Equipment, NHSLA standards and CQC Outcomes, Corporate Records Management Policy.

AUTHOR / FURTHER INFORMATION:

Kim Churchman, Mandatory Training Manager, Organisational Learning and Development.

STAKEHOLDERS INVOLVED:

Mandatory Training Subject Matter Experts

Human Resources, Staff Bank, Recruitment Dept,

Post Graduate Medical Education Centre Manager

Clinical Organisational Learning and Development.

Organisational Learning and Development

DOCUMENT REVIEW HISTORY:

Date Version Responsibility Comments


Aug 12

1.0 Kim Churchman Merged Induction and Stat/Mand policy into one document. Addition of the following:

Escalation process for non attendance/non completion of training.

Revised Induction and update programmes

Summary TNA added

TNA addition and deletion request form

New local induction process for temporary staff

Addition of annual audit plans

Aug 13

1.1 Kim Churchman The following updates were made:

Addition of the mandatory training induction arrangements for all bank staff

Replacement of new induction programmes for all staff groups

Replacement of the TNA summary with the MT refresher training poster

Duties section updated to reflect changes within the Education re-structure including the unified administration service.

Addition of a list of Subject Matter Experts

Update to the monitoring section to include what audits will be undertaken, by when and by whom.

Addition of induction arrangements for staff with honorary contracts

Accountability for MT compliance removed from line managers to all staff members personally.

Addition of the A&C DVD for MT update for A&C / Managerial staff


Contents

Page No Topic

4 Introduction

4 Purpose

4 Scope

5-9 Duties

9-10 Training Needs Analysis

10 Training Course Brochure

10-11 Recording of Induction and Mandatory Training

11 Reporting of Induction and Mandatory Training

11 Bank staff arrangements

11 Agency staff arrangements

12 Contractor staff arrangements

12-13 Corporate Induction for Permanent Staff

14-15 Induction for Bank Staff

15 Induction for Agency Staff

15-16 Local Induction for Permanent Staff

16 Local Induction for Bank Staff

16-17 Local Induction of Agency Staff

17-18 Mandatory Update training

18-20 Managing Non Attendance and Non Completion of training

20-21 Monitoring arrangements

22-23 Appendix One – Definitions

24-25 Appendix Two – Mandatory Training Committee Terms of Reference

26 Appendix Three – Corporate Induction Programme

27-29 Appendix Four – Nurse & Midwifery Induction Programme

30-32 Appendix Five – FY1 Induction Programme

33 Appendix Six – FY2 Induction Programme

34 Appendix Seven – Medical Staff online Induction Programme

35 Appendix Eight – Local Induction Checklist for Permanent Staff

36 Appendix Nine – Flowchart of Local Induction Process for Permanent Staff

37 Appendix Ten – Local Induction Checklist for Temporary Staff

38 Appendix Eleven– Flowchart of the Local Induction Process for Temporary Staff

39 Appendix Twelve – NHSLA TNA Minimum Data Set – Acute

40-41 Appendix Thirteen– NHSLA TNA Minimum Data Set – Maternity

42 Appendix Fourteen – Escalation Flowchart for Non Attendance / Non Completion of training

43 Appendix Fifteen – TNA Additions and Deletion Request Form

44 Appendix Sixteen –Mandatory Training update courses

45-46 Appendix Seventeen – Subject Matter Experts


1.0 Introduction

The Chelsea and Westminster Hospital NHS Foundation Trust recognises the importance of, and is committed to, providing appropriate and relevant training for induction and mandatory updates to ensure that high standards of healthcare are provided ,risks are managed effectively and a safe environment is maintained.

The key to achieving this is to have suitably trained, competent and capable staff that fulfil their role and provide high quality services for patients.

In delivering this training, the Trust will adopt the following principles:

Ensure that every member of staff has the necessary knowledge and skills to meet regulatory requirements enabling them to do their job safely, effectively and these contribute to the overall patient experience.

Cultivate a culture for compliance and emphasise that non-compliance is unacceptable;

Where practical, competence will be measured using a range of assessment methods and these will be recorded on the central database.

Induct new members of staff into the Trust ensuring effective integration into their new work environment;

Provide training in innovative ways, supported by high quality materials and instruction.

Maintain accurate and timely records of all induction and mandatory updates on a central database;

Where appropriate, limit class room learning by utilising alternative appropriate methods of delivery

Make it easier for managers and staff to understand what training is required of them, how to access and maintain the training, and discharge their managerial and individual responsibilities.

Deliver induction and mandatory training updates in accordance with the Trust values.

Evaluate all induction and mandatory training so that the learning experience is a positive one and the training can be applied and is beneficial in practice.

The Mandatory Training Committee (MTC) will manage the provision of induction and mandatory training. These are two aspects of the several training interventions that the Trust provides. The Trust will ensure that no employee will be prevented from receiving induction and mandatory training regardless of disability, age, gender, race, ethnic origin, sexual orientation or religion.


2.0 Purpose

The purpose of this policy is to provide a framework for managers and staff to ensure that there are robust procedures in place so that all staff can participate in the required induction and mandatory update training. It ensures that all induction and mandatory training is regularly reviewed and monitored so that it remains relevant, up-to-date and evidence based.

3.0 Scope

This policy applies to everyone who works for or contributes to the work of the Trust whether they are permanent, temporary, bank, volunteers or honorary members of staff and include those working for Trust partners such as ISS Mediclean, Olympic South Limited (OSL), Norland Building Management Services and Agency employed staff.

4.0 Duties

4.1 Trust Board

The Trust Board has responsibility for ensuring that the organisation has a robust and workable policy for the provision of induction and mandatory training and that the policy is adhered to and resources made available to deliver the training required. In the event of poor compliance, the Trust Board will agree what remedial action will be taken and when to rectify the situation.

4.2 Chief Executive

The Chief Executive has overall responsibility for and has a duty to ensure that the Trust complies with its induction and mandatory training obligations.

4.3 Trust Executive Quality Committee

The Trust Executive Quality Committee will consider and approve any recommendations made by the Mandatory Training Committee (MTC) and will ratify documents or policies relating to induction and mandatory training.

4.4 Mandatory Training Committee (MTC)

The Mandatory Training Committee, chaired by the Director of Human Resources and comprising Subject Matter Experts, training and development leads and divisional education leads is responsible for the co-ordination, design, monitoring and compliance of induction and mandatory training. An annual training plan, based on analysis of need, will be developed.

To ensure the effective management of this, the committee will:

Contribute to the content of the Training Needs Analysis (TNA) ensuring that the correct topics, staff groups and refresher periods are indicated and are appropriate.

Design an effective annual training plan to meet the needs identified in the TNA.

Ensure adequate provision of all induction and mandatory training for all staff that require it.


Ensure the quality of training provision through regular evaluation processes.

Monitor training provision in line with the requirements of the TNA. If there are any deficiencies, recommend corrective action.

Ensure that any action plans are fully implemented, monitored and all actions completed.

Report any threats to compliance with external standards and local policies.

Drive and promote mandatory training compliance within the organisation.

Make recommendations and report induction and mandatory training compliance to other committees as required.

Agree policies and documentation within the Committee’s Terms of Reference (Attached at Appendix Two) relating to induction and mandatory training.

4.5 Divisional Directors

Divisional Directors must:

Ensure compliance with this policy within their divisions.

Ensure the appropriate establishment for staff to undertake their induction and mandatory training.

Ensuring funding is available to support mandatory update training for bank staff.

Ensure and enable attendance at induction and mandatory training in a timely manner

Monitor induction and mandatory training attendance using the training reports produced by the Organisational Learning and Development department and address areas of low or non-compliance.

Understand and accept that the directorate will be fined for repeated non-attendance/ non-completion of induction and mandatory training.

Attend meetings as necessary as part of the escalation process for repeated non- attendance/non-completion of training.

Follow the policy escalation process for managing non-attendance / non-completion of training.

4.6 Divisional Education Leads

Divisional Education leads must:

Provide the conduit between the trust induction and mandatory training strategies and the division and departments

Develop a culture of induction and mandatory training compliance within the division

Ensure induction and mandatory training are prominent in the way the divisions operate

4.7 Clinical Directors / Clinical Tutor

Clinical Directors will ensure that arrangements are in place for the induction and mandatory training of all new medical staff and non training grades within their clinical specialty and follow up non-attendance / non-completion of training.


Clinical tutors will ensure that arrangements are in place for the induction and support of all new post graduate doctors in training to standards set out by the London Deanery and Trust requirements.

4.8 Line Managers

Line managers will:

Ensure that staff are aware of their induction and mandatory training requirements and these are identified and documented during the Trust’s induction and appraisal processes.

Release staff (including long term bank staff) to attend induction and mandatory training in line with the TNA, duties of their post and operational responsibilities.

Review the mandatory training reports monthly cascading information as necessary ensuring that areas of low or non-compliance are addressed.

Ensure that all staff have successfully completed the required induction and mandatory training and follow up those who have failed to attend or complete the training.

Support staff to be fully compliant with their induction and mandatory training requirements at all times.

Ensure that they are familiar with this policy so that they can undertake their duties and fulfil their managerial responsibilities.

Instigate disciplinary procedures for repeated non-attendance/non-completion of training as required in line with this policy

4.9 Staff

All staff must:

Comply with the Induction and Mandatory training policy.

Understand and comply with the induction and mandatory training requirements for their role and be responsible for ensuring that they are fully compliant at all times.

Monitor and manage their own mandatory training compliance and review this annually at appraisal.

Attend, participate and successfully complete the relevant induction and mandatory training.

Carry out their duties in accordance with the training they have received and in line with the Trust values.

Highlight any concerns they may have regarding induction and mandatory training to their line manager.

Understand that repeated non-attendance / non-completion of induction and mandatory training is unacceptable and may result in disciplinary action being taken and their department / division will be fined.

Staff who are not fully compliant with all induction and mandatory topics are required to agree an action plan with their line manager to complete their training as soon as reasonably practicable.


4.10 Subject Matter Experts (SME)

SMEs / Training leads must:

Define the training requirements for each staff group and determine how these will be delivered and met. This must be informed and agreed by the specific committees who the SMEs are responsible to.

Ensure that training content/course outcomes are in line with statute, national guidelines, Cores Skills Training Framework and local requirements and these are approved by the respective committees.

Review annually to course content to ensure its relevance and the learning experience

Advise the Mandatory Training Committee on the type, duration, and frequency of any induction and mandatory training interpreting guidance as appropriate to inform these decisions.

Ensure the provision of the agreed volume of training to meet the need identified in the TNA.

Prepare and deliver the required training.

Ensure that they or staff delivering the training has the appropriate qualifications, knowledge and skills to do so and ensure that these are maintained.

Regularly review the mandatory training reports so that any risks are identified, low compliance acted upon as quickly as practicable.

When monitoring identifies deficiencies, indicate and escalate any shortfalls in training provision to senior staff and the Mandatory Training Committee

Continually review the quality and effectiveness of training provision for their topic(s).

Ensure that attendance registers are accurate and uploaded centrally on the Trust’s Learning Management System, currently Oracle Learning Management (OLM) in a timely manner.

Represent their topic at the Mandatory Training Committee and contribute to the work of this group as per the Terms of Reference.

4.11 Mandatory Training Manager

The Mandatory Training Manager must:

Co-ordinate the provision of induction and mandatory training within the Trust.

Collate the advice from the SMEs and prepare the annual trust wide TNA.

Ensure that all induction and mandatory training meets the course outcomes required by statute, external agencies, Core Skills Training Framework and Trust policies.

Organise, in collaboration with other departments, the annual training course brochure to meet the needs identified in the TNA.

Publish the TNA on the Trust’s intranet for all staff to access.

Distribute the monthly mandatory training reports

Highlight and escalate any deficiencies in the provision of induction and mandatory training to the Head of Organisational Learning and Development or Clinical Organisational Learning and Development.


Co-ordinate meetings with Divisional Directors, line managers and HR Business Partners to instigate disciplinary processes for repeated non-attendance / non completion of training

Regularly review the capability and production of the mandatory training reports highlighting any deficiencies as they occur

Produce the annual training report for Induction and Mandatory Training

4.12 Organisational Learning and Development Department

Have overall responsibility for managing the delivery of induction and mandatory training.

Update, manage and train end users on the Trust’s central learning database (currently OLM) and ensure that all induction and mandatory training is recorded.

Co-ordinate all mandatory training records in collaboration with the SMEs.

4.13 Education Administration Team

The Education Administration team will:

Administer all aspects of induction and mandatory training and record attendance on the Trust’s central learning database (currently OLM).

Schedule and book staff into induction and updates as required

Follow up DNAs or non-completion of induction and mandatory training including e-learning programmes in line with the escalation process described in this policy.

Notify the Mandatory Training Manager monthly of staff that have not attended or not completed induction and mandatory training on 3 or more occasions.

4.14 Post Graduate Medical Education Centre (PGMEC)

The Post Graduate Medical Education Centre must:

Agree the content and provision of induction and mandatory training programmes for medical staff in line with the TNA, external requirements, SME advice and the London Deanery

Co-ordinate and arrange the induction for the FY1 and FY2 doctors and other training grades joining the Trust

Collate attendance list and evaluations for the inductions held in August and record these on the Trust central learning management database (currently OLM).

Follow up non-attendance at the inductions and report non-attendance to the clinical tutor and Divisional Managers in line with the escalation process described in this policy.

4.15 Staff Bank Department

It is the responsibility of the staff bank department to:

Co-ordinate the induction of bank nurses and support workers monthly.


Review timesheets and ensure payment for induction of bank staff who attend induction or mandatory training.

Record attendance at bank induction on the central learning management database (currently OLM)

4.16 Recruitment Department (HR)

If a member of staff commences employment from another Trust and belongs to a London Passport scheme, the recruitment department may request their training records to be transferred over to the Trust’s training record system (OLM). The recruitment team will manage such requests. This information will come through automatically to the administration teams via the workflow notifications from Electronic Staff Record (ESR).

4.17 Agency / Agency Framework

The agency or agency framework is responsible for the provision of induction and mandatory training and are obliged to follow the terms and conditions of the contract for induction and updates included within The London Procurement Programme (LPP).

5.0 Training Needs Analysis (TNA)

5.1 The Trust’s induction and mandatory training requirements are detailed in the TNA. The full TNA is located on the Trust’s intranet for all staff to access. A summary of training requirements, by course, is detailed in Appendix Sixteen. Training is planned annually (usually in January) for the forthcoming year. The training year runs from April to March inclusive and follows the financial year.

5.2 Training requirements are determined using a combination of analysis of need, risk assessment, available resources, professional guidelines and individual staff group requirements. The TNA comprises topics required by statute, external standards and Trust policy.

5.3 The SMEs will advise the Mandatory Training Committee, following approval from their relevant committees or groups, on the type, duration, frequency and applicable staff groups for their individual topics. The Mandatory Training Committee will consider the inclusion of such training, and will approve any new training requirements.

5.4 All new mandatory training requirements must be submitted to, reviewed and agreed by the Mandatory Training Committee prior to implementation. A TNA additions and deletions form (attached at Appendix Fifteen) must be completed and submitted for approval to the committee. Unless there are major legislative amendments required in year, the TNA will remain in place until its next review.

5.5 The Mandatory Training Manager will collate the approved training requirements and record this as the TNA. The TNA will detail the training required, who needs to complete the training, delivery methods and the frequency of refresher training.

5.6 The chair of the MTC will present the TNA to the Trust Board for approval annually. Once approved, this will be published on the Trust intranet for all staff to access


5.7 Any changes made to the TNA will be communicated to the Trust by the Mandatory Training Manager via the Daily Noticeboard bulletin and divisional education leads.

5.8 The Mandatory Training Manager will regularly review all training requirements in new policies and guidelines and will clarify these as necessary. The TNA will only be updated when policies are ratified and the additions and deletions process has been followed and approved.

5.9 Where deficiencies are highlighted during the monitoring process, an action plan will be developed. This plan will be submitted to the Director of Human Resources via the Mandatory Training Committee. The MTC will be responsible for overseeing the action plan until all actions are fully implemented.

6.0 Training Course Brochure

A training course brochure will be co-ordinated, developed and published annually for the forthcoming year, by the Organisational Learning and Development Department. This will reflect the training requirements identified in the Trust’s TNA alongside other training topics.

7.0 Recording of Induction and Mandatory Training

7.1 The Trust will record all induction and mandatory training, on a central learning management system (currently OLM).

7.2 SME/training leads that are trained to use OLM or have dedicated administration support are required to record completion of training on OLM within 5 days of the training taking place.

7.3 Attendance lists should be kept in line with the Trust’s Corporate Records Management Policy and held centrally in the Organisational Learning and Development Department.

7.4 All SME/training leads that have not been trained to use OLM or who do not have dedicated administration support, are required to have an attendance list at each training session they deliver and are required to send a copy of the list to the Organisational Learning and Development department who will record the training on their behalf within 5 days of the training taking place. The original attendance list will be retained in line with the Corporate Records Management Policy within the Organisational Learning and Development Department.

7.5 All training undertaken via Learn online will automatically be recorded in OLM upon successful completion.

8.0 Reporting of Induction and Mandatory Training

8.1 Key topics of induction and mandatory training will be reported on monthly (currently via Qlikview) . This includes topics required by statute, external agencies, best practice guidelines and trust specific requirements.


8.2 Detailed training reports, compiled monthly, show induction and mandatory training compliance by division, department and individuals. They also indicate outstanding induction and mandatory training and are RAG rated to assist in prioritising training requirements. This is available to managers to enable them to check and follow up induction and mandatory training.

8.3 An annual training report covering all topics within the TNA will be produced by the Mandatory Training Manager. This will be presented to the Mandatory Training Committee, Executive Quality Committee and Quality Assurance Committee respectively. Additional quarterly reports will also be produced as requested.

9.0 Bank Staff

9.1 Bank staff engaged by the Trust will be required to attend and complete induction

training. This will be completed using a combination of class-room based sessions and e-learning and attendance will be funded by the divisions. If training has not been successfully completed then no shifts will be offered.

9.2 Bank staff registered with the Trust for more than two years will be required to attend and complete mandatory updates in line with their role and the requirements in the Trust’s TNA. Funding for this will also be met by the divisions.

10.0 Agency Staff

10.1 The London Procurement Programme is responsible for supplying and providing induction and mandatory training for all agency staff from the following staff groups: Medical locums, Nurses, Midwives, Admin and Clerical staff and Allied Health Professionals

10.2 The London Procurement Programme is responsible for auditing the induction and mandatory training undertaken by agency staff and provides the Trust with a report to this effect annually.

11.0 Contractor staff

11.1 For contractor staff working with ISS Mediclean, Olympic South Limited and Norland, it is the responsibility of the general manager in Facilities to ensure that induction and update mandatory training is completed in line with the contractual agreement.

11.2 It is the responsibility of all other individual line managers to check and ensure that any other contracted staff attend and complete their induction and mandatory training in line with the TNA depending upon the duration of their contract with the Trust and requirements of their role.


12.0 Staff with Honorary contacts

12.1 It is the responsibility of all line managers to undertake a risk assessment and to check and ensure that any staff with honorary contracts attend and complete their induction and mandatory training in line with the TNA depending upon the duration of their hours with the Trust and their role.

13.0 Induction Procedures

13.1 Corporate Induction Processes for Permanent Staff

Corporate Induction – All staff (excluding Medical Staff)

Content -This is an interactive facilitated programme for all new permanent staff (excluding medical staff). Attendance is mandatory and should take place within 8 weeks of commencing employment with the Trust. Please refer to Appendix Three for the corporate induction programme.

Booking process

-The Education Administration Team automatically receives daily workflow notifications from ESR of new staff joining the Trust. They will book all new starters (except permanent medical staff ) into the next available corporate induction or within 8 weeks of their start date.

Recording Completion

-A register of attendance will be prepared for Corporate Induction.

-Upon completion of the face to face induction and any associated e-learning, delegates learning records will be updated on OLM and the attendance register retained.

Nurse and Midwifery Induction – All Nurses, Midwives, Maternity Support Workers (MSW) and Healthcare Assistants (HCA)

Content -This is a 3 day programme using a combination of face to face training, and e- learning. All e-learning must be completed by the end of the 3 day course. Please refer to Appendix Four for programme content.

Booking process

-The Education Administration Team automatically book new nursing and midwifery staff including HCAs and MSWs into the 3 day nursing and midwifery induction or within 8 weeks of commencing employment with the Trust.


-A register of attendance will be prepared for the 3 day programme.

-The Education Administration Team will confirm and record attendance on OLM upon successful completion of the face to face session and e-learning.

-All e-learning modules will be automatically recorded in OLM upon completion

Medical Staff Induction- All grades of medical staff

Content -The FY1 and FY2 course programmes are a mixture of face to face training and online learning. Please refer to Appendices Five and Six for content.

- For all other grades of medical staff an online induction programme is provided Please refer to Appendix Seven for content.

Booking process

-The Post Graduate Medical Education Centre automatically receive daily workflow notifications of all new medical staff joining the Trust from ESR

-For FY1 and FY2 doctors, the PGMEC arrange and invite these staff to attend a face to face training session in August each year


-For all other grades of medical staff, the PGMEC register these staff onto Learn online and send an e-mail which tells them how to access the system and details the modules that they need to complete.

NB -No study leave is granted until the induction is complete


The PGMEC record attendance at the FY1 and FY2 induction on OLM upon successful completion including associated e-learning

- The PGMEC run reports monthly from OLM to check that all e-learning modules have been completed.

-Doctors are given one calendar month after commencing employment in the Trust to complete the online modules

-Online modules completed on learn online will be automatically recorded in OLM upon successful completion

For staff who work part-time, line managers will need to ensure that they attend the corporate induction and apply discretion in offering time owing or additional payments for attendance. Any time owing or payments will be met by the division.

In exceptional circumstances staff who are unable to attend a face to face induction can complete the online modules by prior arrangement with the Organisational Learning and Development Team and their line manager.


13.2 Induction processes for Bank staff

Induction – Bank staff

Content -This is a combined programme of tutor led and e-learning courses provided by the Trust for all bank staff.

Booking / completion

process

-For bank Nurses, Midwives, HCAs and MSWs

-The staff bank department will schedule all new bank Nurses, Midwives, HCAs and MSWs into their 2 day induction.

-EPR training and e-learning modules will be completed on day 2 of the induction programme

-For “bank only” Nurses/Midwives and HCAs / MSWs the bank staff member is required to attend and complete induction training prior to commencing any shifts.

-Payment for induction will be made at a flat rate of £100 per day for Nurses/Midwives and £75 per day for HCA s/ MSWs

-The flat rate payment will be made to the bank staff member on completion of 5 shifts

-The staff bank department will review the timesheets on a monthly basis against whether the bank staff member has worked the 5 shifts and make the payment accordingly.

-The payments will be cross charged to the directorates on a quarterly basis by the staff bank department

-For bank medical staff

-The PGMEC will issue all new bank medical staff with a user name and password to access Learn online and the e-learning induction modules.

.The doctor will be required to complete the modules within one month of starting at the Trust.

-For bank Admin & Clerical staff

-The Education Administration Team will issue all bank Admin and Clerical staff with a username and password for Learn online and the e-learning modules.

- The e-learning modules will be completed prior to commencing work in the Trust.

-For bank AHP staff

The Education Administration Team will issue all bank AHP staff with a username and password for Learn online and the e-learning modules.

- The e-learning modules will be completed prior to commencing work in the Trust.

-For bank Therapy staff

The Education Administration Team will issue all bank Therapy staff with a username and password for Learn online and the e-learning modules.

- The e-learning modules will be completed prior to commencing work in the


Trust.

-Bank therapy staff will be required to attend the Therapies Manual handling and Basic Life support induction course.


-All e-learning modules completed via Learn online will be recorded automatically in OLM upon successful completion

-The staff bank department will record attendance at the nurse and midwifery induction on OLM after successful completion of the face to face sessions and e-learning

-The Manual Handling team will record completion of the Therapies induction

13.3 Induction Process for Agency Staff

Induction – Agency Staff

Content -There is separate content of induction training within the terms and conditions for the following staff groups within the London Procurement Programme Agency Framework:

- Admin and Clerical Staff

- Nursing and Midwifery Staff

- Allied Health Professional Staff

- Medical Locums

Booking process

- The framework is responsible for supplying the training /induction to agency members


- The supplier will keep written records of the training undertaken including the following:

- Who provided the training

- The dates the training was received

- Where the training took place eg location or media (electronically)

- The extent of the training including duration and content

13.3 Local Induction Process for Permanent Staff

Clinical and Non-Clinical Staff

Content -The minimum content of the local induction for permanent staff is attached at Appendix Eight

Process - Using the local induction checklist for permanent staff, the line manager is responsible for ensuring that a local induction is carried out to ensure that new staff can work safely and effectively within a ward or designated area.

-This induction is in addition to the corporate and/or clinical inductions and enables new staff to be acquainted with their new work environment , they understand the role they are expected to perform and are aware of all information, policies and procedures relating to their individual ward / department

-This induction should be carried out within the first week of employment and the local induction card signed by the new starter and their line manager. Upon completion the checklist is to be sent to the Education Administration


Team

-In addition to the minimum requirements indicated on the local induction checklist for permanent staff, areas may choose to have their own, more detailed local induction pack. This should be used to supplement the local induction checklist and can be continued beyond the first week of employment if necessary

-Line managers must decide, in consultation with the new staff member, what items need to be covered depending on the role and the individual

-A flowchart indicating the local induction process for permanent staff can be found at Appendix Nine


-Upon receipt of the signed local induction checklist the Education Administration Team will record completion of the local induction on OLM

-The checklist will be returned to the ward / department for filing in the new starter’s personal file

13.4 Local Induction Process for Bank Staff

(Clinical and Non-Clinical Staff)

Content - The minimum content of the local induction for bank / temporary staff is attached at Appendix Ten

Process -Using the local induction checklist for temporary staff, line managers must carry out a local induction so that staff are provided with key information to ensure that they can work safely and effectively within a ward or department. The induction needs to be carried out irrespective of the duration that a bank/ temporary staff member is required to work, whether this is one day or longer. This process enables the bank/temporary staff member to become acquainted with the local work environment so that they understand the role they are expected to perform and are aware of essential safety information, policies and procedures relating to the designated area

-This induction should commence on the first day of a shift or assignment in the Trust

-Line managers or supervisors are required to carry out the induction and complete the checklist and declaration


-Lin- The White copy of the declaration is sent to the Education Administration Team who record the local induction on OLM

The -The Blue copy is retained by the line manager in the ward / department

|T -The local induction card is given to the bank / temporary staff member to retain for future reference

13.5 Local Induction Process for Agency Staff

(Clinical and Non-Clinical staff)

Content - The minimum content of the local induction for temporary staff is attached at Appendix Ten

Process -Using the local induction checklist for temporary staff, a local induction is mandatory for agency staff so that they are provided with key information to ensure that they can work safely and effectively within a ward or department.

An induction needs to be carried out irrespective of the duration that an agency staff member is required to work. This process enables the agency staff member to become acquainted with the local work environment so that they


understand the role they are expected to perform and are aware of essential safety information, policies and procedures relating to the designated area

- This induction should commence on the first shift in the Trust

- A flow chart indicating the local induction process for agency staff can be found at Appendix Twelve


-The White copy of the declaration is sent to the Education Administration Team who record the local induction on OLM

-The Blue copy is retained by the line manager in the ward / department

-The local induction checklist is given to the bank / temporary staff member to retain for future reference

14.0 Mandatory Updates

14.1 Staff (including long term bank staff) will be booked into a mandatory update 6 weeks in advance of the expiry date and no later than 6 weeks after the expiry date. Course details are as follows:

14.2 Bank staff attending updates will be paid according to their grade for the duration of the update. These costs will be met by the divisions.

Title Maternity Updates

Training Requirements

As per the Training Needs Analysis

Booking Process - All staff will be automatically scheduled to attend the appropriate update annually by the Maternity department


-Training will be recorded on OLM by the Education Administration Team and all e-learning automatically into the staff members learning record in OLM.

Non Attendance / Non completion

- Follow up will take place as per the escalation process in this policy

Title Nursing Update

Training Requirements

Day 1 Day 2

Nurses

Healthcare Assistants

Booking Process -Nursing staff will be booked into an update by the Education Administration Team


-The Education Administration Team will record completion of training on OLM and e-learning will be automatically be recorded in the staff members learning record upon completion



Title Administration and Clerical Update (including board members)

Booking Process -A&C staff who require an update will be sent details and are required to view the mandatory training DVD and complete the online assessment.


-This will be recorded automatically in OLM upon successful completion




Title AHP Update (For Pharmacy staff, Dietetic staff, Healthcare Scientists and Speech and Language Staff

Booking Process -The Education Administration Team will book staff into an update when required in line with the requirements in 14,1


-The Education Administration Team will record completion of training on OLM and e-learning will be automatically be recorded in the staff members learning recordupon successful completion.



Title Therapies Update (For Physiotherapy , Occupational Therapy and Radiology Staff)

Booking Process -The Education Administration Team will book staff into an update when due in line with the requirements in 14.1


-The Education Administration Team will record completion of training on OLM and e-learning will be automatically be recorded in the staff members learning record upon successful completion.



Title Medical Staff Update (All grades except FY1 and FY2)

Booking Process -The PGMEC will notify medical staff when their update is due and enrol them onto the e-learning modules they require. For Fire, BLS, H&S and Slips Trips and Falls training, Medical staff are required to book into a Consultant / SpR Update via Eduadmin


-The Education Administration Team will record completion of training on OLM and e-learning will be automatically be recorded in the staff members learning record upon successful completion



Specific course content for each update can be found in the training course brochure on the intranet.

14.2 Managers will ensure that staff are released to attend. Where managers fail to schedule or release staff for training, an investigation must be undertaken and where appropriate disciplinary action may be taken.

14.3 If a member of staff fails to attend pre-booked training, line managers are required to follow this up. This includes tutor led sessions and e-learning. The Trust views non-attendance / non-completion of mandatory updates seriously. Where staff repeatedly fails to attend training, an investigation must be undertaken and where appropriate disciplinary action may be taken.


15.0 Managing Non-Attendance / Non-completion of training

15.1 If a staff member fails to attend induction or mandatory training or fails to complete associated e-learning, the following process will apply:

On 1st DNA / non-completion of e-learning, an email will be sent via personal and trust email to the staff member and their line manager informing them of non-attendance or non-completion of training.. The staff member will automatically be re-booked to attend the next induction or update and the line manager required to follow up non completion of e-learning.

On 2nd DNA / non completion of e-learning an email will be sent to the Divisional Director, line manager and the staff member advising of second non-attendance and/or non-completion of e-learning. The Divisional Director and line manager must not support or fund other learning activities until induction or update training is complete. The directorate will also be fined £90 per delegate for non-attendance / non completion (excluding sickness).

On 3rd DNA / non completion of e-learning, the Mandatory Training Manager will set up a meeting with the Divisional Director, Line Manager and HR Business Partner to investigate and commence the 1st stage of the disciplinary process. The directorate will be fined a further £90 per delegate. The line manager will ensure attendance / completion of the required training through the disciplinary process.

A summary of the quarterly cross charges will be presented to the Mandatory Training Committee and the Executive Quality Committee.

15.2 Delegate Arrives late

If a delegate arrives late (more than 10 minutes after the course has started), they will not be permitted to join the class and the delegate will be sent back to their workplace. If attending an update, they will be required to re-book, if attending induction; they will automatically be re-booked to attend the next induction.

15.3 Managing Persistent Non-Attenders

A persistent non attender is someone who fails to attend or fails to complete e- learning on three or more occasions. The Mandatory Training Manager will set up a meeting with the Divisional Director, the line manager and the HR Business Partner who will be expected to commence an investigation and consider disciplinary action against the non-attender where appropriate.

15.4 Sanctions for Non-Attendance / Non-Completion

The following sanctions will apply:

For 2 or more DNA’s, the directorate will be fined £90 per delegate on each occasion


For staff who DNA or fail to complete the required training on 2 or more occasions the line manager should withhold and not support other learning activities until Induction or mandatory training is complete.

For the 3rd DNA or non completion, the Divisional Director and line manager should instigate a disciplinary investigation and consider disciplinary action. The outcome of the investigation must include attendance at the required training.

15.5 Fines will be applicable to corporate induction, nursing and midwifery inductions and all mandatory updates and will exclude local induction. Monies from the fines will be transferred into a central budget. This money will be used for future educational activities as agreed by the Director of Multi-Professional Education.

15.6 Cancelling course attendance

If a staff member is unable to attend training, they must contact the Education Administration Team as soon as possible to cancel their place. Staff who fail to cancel within 48hours of the course date will be fined £90. This excludes exceptional or unforeseen circumstances.

16.0 Monitoring

16.1 All staff are accountable for and are required to monitor their own induction and mandatory training in line with the TNA so that they are compliant at all times.

16.2 The Mandatory Training Committee will monitor the effectiveness and implementation of this policy across the Trust. To support this, the Mandatory Training Manager will oversee induction and mandatory training on an on-going basis, and will report to the executive quality committee on the following:

How the organisation records that all new permanent staff complete corporate and local induction

How the organisation records that all new temporary staff complete local induction

How the organisation follows up those who do not complete corporate and local induction

How the organisation records that all permanent staff complete relevant training in line with the Training Needs Analysis

How the organisation follows up those who do not complete relevant training programme.

16.3 The following audits will be completed annually

Staff Group Training audited Responsibility

Medical Staff Induction and Updates as identified in item 16.2

Organisational Learning and Development Department

All new staff Corporate Induction and Local Induction for permanent and temporary staff as



identified in item 16.2

Nursing Nursing and Midwifery Induction and Nursing Updates as identified in item 16.2


Maternity Maternity Updates and MOMS as identified in item 16,2


All staff Mandatory Training as identified in item 16.2


Any exceptions will be reported to the Director of HR via the Mandatory Training Committee. Areas of non-compliance identified through the monitoring processes will be recorded and actions to resolves these will be incorporated into the overall mandatory training action plan. This will be monitored via the mandatory training committee and the executive Quality Committee.


Appendix One - Definitions

Agency staff – Temporary staff employed through an employment agency or agency

framework.

Bank staff – Staff who are temporary and engaged by the Trust as and when required.

COLD – Clinical Organisational Learning and Development Department

Clinical Induction – (Nurses, Midwives, Maternity Support Workers (MSW) and Healthcare Assistants (HCAs) – A three day programme of instruction and e-learning, in addition to the corporate and local inductions.

Contracted staff - Staff employed under a specific agreement / contract that is legally binding between two or more parties with mutual obligations to undertake a specific piece of work

Corporate Induction - A one day programme for permanent staff organised by the Education Administration Team / Organisational Learning and Development Department.

DNA – Did Not Attend

Doctors (medical staff) Induction - This is an e-learning package for consultants, SpRs and STs and any other doctor, of any grade, that does not start in August. A separate tutor led induction is organised in August each year for the intake of FY1 and FY2 doctors. These are organised by the Post Graduate Medical Education Centre.

ESR – Electronic Staff Record. This is the HR database used to maintain staff records

Local Induction - An induction that takes place in a ward or department via an induction checklist and /or an induction pack for both permanent, bank and agency staff that introduces the new staff member to their individual work areas.

Locum staff – These are staff, usually employed through and agency, who cover professional positions eg medical staff. (Assurance of mandatory training provided to locum staff will be sourced from the agencies used)

LPP – London Procurement Programme

Long term bank staff – Staff who has been engaged in a bank position for over 12 months

Mandatory training – Training that is detailed in Trust policy, national and regional policies and guidelines, local requirements and best practice that is compulsory for staff to attend


MTC – Mandatory Training Committee

NHSLA – National Health Service Litigation Authority

OLD – Organisational Learning and Development Department

OLM – Oracle Learning Management System. This is the trust’s central database for training

PGMEC – Post Graduate Medical Education Centre

Persistent non-attender – Someone who fails to attend on 3 or more occasions or who fails to re-book on 2 or more occasions following a DNA

SME – Subject Matter Experts

Statutory training – Training that is detailed in law / statute.

TNA – Training Needs Analysis - is a schedule of training that has been identified and approved by the Mandatory Training Committee


Appendix Two – Mandatory Training Committee Terms of Reference

TERMS OF REFERENCE

Mandatory Training Committee

Purpose of the Group

The purpose of this group is to coordinate, implement the design and management of, an annual training plan to meet all mandatory training requirements, based on an analysis of need to ensure the Trust’s effective management of mandatory training.

Membership

The group will be chaired by the Director of Human Resources and comprise the following members:

Subject Matter Experts

Training and Development Leads

Governance Leads

Education leads / representatives from each division

Other individuals will be co-opted to attend as required.

Duties and Responsibilities

Committee members are expected to share their knowledge and expertise with the group offering expert advice as necessary. They will also be required to communicate to and from the committee to the divisions.

Other responsibilities:

To contribute to the annual Training Needs Analysis (TNA) ensuring that the correct topics, staff groups and refresher periods are included

To design an effective and efficient training schedule to meet the needs of the TNA

To ensure adequate provision of training to meet the TNA

To highlight any deficiencies that prevent the delivery of the training required

To report any threats to compliance with external standards

To agree additions, amendments and deletions of mandatory training provision

To monitor the quality of mandatory training provided in line with local and national requirements

Nominees

The core members will ensure that an appropriate nominee attends on their behalf when they are not available. The nominee should be fully informed and be able to reflect the views of the core members

Quorum

A quorum will consist of a chair or nominated person and 5 other persons made up from Subject Matter Experts, Training and Development leads and Governance leads


Frequency

Meetings will be held every two months and prior to an assessment monthly.

Attendance requirements

Members of the committee are required to attend a minimum of 3 meetings throughout the year.

Circulation of papers and minutes

Papers for meetings will be distributed to committee members two weeks in advance and the minutes circulated within 10 days of the meeting taking place.

Reporting

The Mandatory Training Committee will report to the Quality Committee through regular submission of reports. Update reports will be made available to other groups as required.

The following groups will report to the Mandatory Training Committee:

OLM user group

Authority

The Mandatory Training Committee is authorised by the Quality Committee to seek any information it requires from any employee, group or committee in pursuit of its Terms of Reference and all are directed to co-operate with any request made to the group.

NHS Litigation Authority Standards

There are a number of NHSLA standards relevant to this committee.

The standards change on an annual basis and the committee will be made aware of these changes as they take place.

Monitoring arrangements

The committee will be required to oversee the completion of any action plans and / or audits in line with any monitoring arrangements.

The overall effectiveness of this group will be monitored by the Quality Committee

The Terms of Reference will be reviewed every 12 months.


Appendix Three – Corporate Induction Programme


Appendix Four – Nurse and Midwifery Induction Programme


Appendix Five – FY1 Induction Programme 2013

FOUNDATION YEAR 1 INDUCTION Postgraduate Medical Centre DAY 1 8.30 Registration 9.15 Welcome and Introduction Postgraduate Medical Education and Training 9.30 Tips for FY1s 10.30 Undergraduate Teaching 10.40 Medicine Management including VTE Risk Assessment, Prudent

Antibiotic prescribing 11.20 Blood Transfusion 11.45 Pathology 12:00 Radiology 12:15 Clinical Risk 12.45 Information Governance 14.15 Infection Prevention and Control 14:35 Fire, H&S, Slips Trips and Falls 15:35 Hospital at Night

Meet with members of Medicine/Surgery Directorates – rotas, EWTD etc

16:30 Close


FOUNDATION YEAR 1 INDUCTION Postgraduate Medical Centre DAY 2 8.45 Registration 9.15 EPR Training (including Health Record Keeping

training) or Resuscitation Training 12.30 Lunch Resuscitation Decisions Coroner 1.30 EPR Training (including Health Record Keeping

training) or Resuscitation Training DAY 3 9.00 Registration 9.15 Mandatory E-Learning Modules Equality & Diversity Moving & Handling Child Protection or Practical Skills 12.00 Lunch 12.45 Mandatory E-Learning Modules or Practical Skills


FOUNDATION YEAR 1 INDUCTION Postgraduate Medical Centre DAY 4 Attend Handovers 9.00 Medicine 8.00 General Surgery & Urology 7.45 Trauma & Orthopaedics 8.00 Anaesthetics/ITU 8.00 Obstetrics & Gynaecology 9.00 Psychiatry Departmental Inductions Shadow current FY1 doctors DAY 5 Shadow current FY1 doctors


Appendix Six – FY2 Induction Programme

FOUNDATION YEAR 2 INDUCTION

Postgraduate Medical Centre

8.30 Registration

9:00 Introduction - Postgraduate Medical Education and Training

09:20 Fire, Health & Safety, Slips, Trips and Falls

10:20 Blood Transfusion

10:50 Pharmacy

11:20 On call rotas

11:45 Radiology

12:00 Pathology

12:15 Information Governance

12:30 Tour

13:30 EPR Training (including Health Record Keeping)


Appendix Seven – Medical Staff Online Induction Programme

MANDATORY ON-LINE INDUCTION PROGRAMME FOR

ALL DOCTORS

This induction consists of the following 20 modules:

Clinical Risk Management

Consent to Treat

Infection Control

Occupational Health & Safety

Pain Management

Complaints

PALS

Medicines Management

Safeguarding Vulnerable Adults

Working at Chelsea & Westminster

Workplace based Assessment

How to give Feedback

Doctor’s local Manual Handling

VTE Prevention and Treatment

Introduction to Information Governance

Manual Handling Awareness

Safeguarding Children Level 2

Equality and Diversity General Awareness

Blood Transfusion – Blood components and indications for use

Blood Transfusion – Consent to Transfusion


Appendix Eight – Local Induction Checklist for Permanent Staff


Appendix Nine - Flowchart for the Local Induction of Permanent Staff

Local Induction Process for Permanent Staff

New starter receives pack from HR including local induction checklist

New starter brings in the local induction checklist on their first working day

Line manager carries out the local induction

Line manager and new starter sign and date the checklist when complete

Completed checklist sent to the Education Administration Team

Education Administration Team receives local induction checklist

Education Administration Team records completion of the local

induction on OLM

Education Administration Team cross reference new starter with

monthly new starter report

Education Administration Team updates new starter report with completion date of local induction

Education Administration Team send card back to line manager for filing

Monthly monitoring of the new starter report vs local induction

Local induction complete

No further action

Local induction not competed

Education Admin Team send follow up letter to line manager

Education Administration Team updates new starter report


Appendix Ten – Local Induction Checklist for Temporary Staff


Appendix Eleven – Flowchart for the Local Induction of Temporary Staff

Ward / Dept. request a temporary member of staff

Temp staff member given placement info verbally over the telephone

Temporary staff member attends assignment/placement

Line manager or equivalent carries out local induction

Checklist and declaration completed by temp staff member and manager

White copy of declaration sent to Education Administration Team

Blue copy retained in ward / department

Checklist given to temp staff member

Education Administration Team record local induction on spreadsheet

Staff bank send list of new staff bank members weekly to the Education Administration Team

Education Administration Team check declarations received against new staff members and follow up non completions


Appendix Twelve – TNA Minimum Data Set for Acute Trusts

A. Training Needs Analysis (TNA) Minimum Data Set Within the NHSLA risk management standards there are key subject areas in relation to risk which incorporate aspects of training. The organisation must therefore ensure it includes the following areas of risk management training within the training needs analysis at 1.3.5. Please note this list is not exhaustive and if any additional risk management training specific to the organisation is provided this could be included within the evidence. The list below applies to all NHS trusts providing acute, community or mental health & learning disability services and non-NHS providers of NHS care, except where otherwise indicated. As a minimum the following must be included:

Standard 1 • Health Record-Keeping Training (criterion 1.8)

Standard 2 • Investigation of Incidents, Complaints & Claims Training (criterion 2.5) Standard 3 • Risk Awareness Training for Senior Management (3.6) • Moving & Handling Training (criterion 3.7) • Harassment & Bullying Training (criterion 3.8) Standard 4 • Violence & Aggression Training (criterion 4.2)

Slips, Trips & Falls Training (Staff & Others) (criterion 4.3) • Slips, Trips & Falls Training (Patients) (criterion 4.4) • Hand Hygiene Training (criterion 4.6) • Inoculation Incident Training (criterion 4.7) Standard 5 - Organisations providing acute and community services and non-NHS providers of NHS care • Consent Training (criterion 5.3) • Transfusion Process Training (criterion 5.8) • Venous Thromboembolism Training (criterion 5.9) • Medicines Management Training (criterion 5.10)


Appendix Thirteen – TNA Minimum Data Set for Maternity Standards

As a minimum the following must be included:

Standard 1

1.10 Skills & Drills Training:

― Cord Prolapse

― Shoulder Dystocia

― Vaginal Breech

― Antepartum & Postpartum Haemorrhage

― Eclampsia

Standard 2

2.3 Continuous Electronic Fetal Monitoring

2.8 Early Recognition of Severely Ill Pregnant Women

2.8 Maternal Resuscitation

Standard 3

3.5 Assessment & Management of all Types of Perineal Trauma

3.6 Shoulder Dystocia

3.7 Postpartum Haemorrhage

Standard 4

4.5 Maternal Antenatal Screening Tests

4.6 Mental Health Training - to include as a minimum: maternal mental health disorders, risk assessment methods and referral routes

Standard 5

5.2 Newborn Life Support

5.5 Newborn Feeding

5.6 Full Physical Examination of the Newborn

5.10 Care of Women Following Operative Interventions*

* It is not expected that this training includes staff who are employed in a recovery role


Appendix C: Maternal Antenatal Screening Tests - Minimum Data Set

The CNST Maternity Clinical Risk Management Standards focus on the maternal antenatal screening tests which follow the UK National Screening Committee guidance. The maternity service must therefore ensure that it includes the following tests as a minimum, within approved documentation at 1.4.5.

As a minimum the following tests must be included:

Fetal Anomaly Screening

Fetal anomalies

Down’s syndrome

Infectious Diseases in Pregnancy Screening

Hepatitis B

Human immunodeficiency virus

Rubella susceptibility

Syphilis

Sickle Cell & Thalassaemia Screening

Sickle Cell & Thalassaemia


Appendix Fourteen – Escalation Flow Chart for Non Attendance / Non Completion of Training

Escalation Steps for all Mandatory Training

(Including Corporate Induction, Nursing and Midwifery Induction and Update days)

Staff member completes – no further action required

Step 1

Staff member booked onto Induction or update as appropriate within specified time frame

Staff member fails to complete training (including e-learning modules)

Step 2

1st DNA / non completion of e-learning = Notification of non attendance / non completion sent via personal and trust email to the line manager, staff member and matron.

Staff member automatically re-booked on next available programme. New course date and details sent in email.

Step 3

2nd DNA / non completion of e-learning – email sent to line manager, staff member, matron and Divisional Director advising of 2nd non attendance / non completion of e-learning

Divisional Director and Line manager required not supporting or funding other learning activities until induction / e-learning is complete.

Directorate is fined £90 per delegate for non attendance or non completion (exc sickness)

Step 4

3rd DNA/ non completion of e-learning – Meeting set up with Divisional Director, Line Manager and HR to start 1st stage of disciplinary process

Directorate is fined a further £90 per delegate for non attendance / non completion

Manager ensures completion of training through the disciplinary process.


Appendix Fifteen – TNA Additions and Deletion Request Form

Training Needs Analysis – Additions and Deletions Form

Please complete this form if you would like to add or delete item(s) from the Trust’s Risk Management Training Needs Analysis.

NB : Additions and deletions will only be made after approval by the Mandatory Training Committee.

Additions to the TNA

Topic / Name Why addition to TNA required eg Trust Policy, Statute, best practice

Staff Groups training is applicable to

Delivery Method eg Face to Face, e-learning, Other

Refresher Period

Items to be removed from the TNA

Topic / Name Why item needs to be removed

Staff Groups training was applicable to

Current Delivery Method eg Face to Face, e-learning, Other

Current Refresher Period


Appendix Sixteen– Summary of update training requirements


Appendix Seventeen – Subject Matter Experts

Mandatory Training Topic Subject Matter

Expert / Committee Line Manager Exec Director

Blood Transfusion David Mold / Blood Transfusion Committee

Lead for Clinical Learning and Development

Director of Nursing

Children (Safeguarding )

Harriet-Anne Thomas / Safeguarding Committee

Matron for Paediatrics

Director of Nursing

Equality & Diversity Priti Bhatt / Equality & Diversity Steering Group

Deputy Director of HR

Director of HR

Fire Kevin Ray / Health & Safety Committee

Head of Estates and Facilities

Director of Governance

Harassment & Bullying Priti Bhatt / Equality Diversity Steering Group

Deputy Director of HR

Director of HR

Health Record Keeping Vivia Richards / Medical Records Committee



Health & Safety Kevin Ray / Health & Safety Committee



Induction Kim Churchman / Mandatory Training Committee

Lead for Organisational Learning and Development

Director of HR

Infection Control / Hand Hygiene Roz Wallis / Infection Control Committee

Director of Nursing Director of Nursing

Information Governance Byron Charlton / Director of IT Director of Operations

Inoculation Incident Desiree Lindsay (RMH)

Julie Welsh (RMH) Director of HR

Medicine Management

Sam Copp / Medicines Management Committee

Head of Pharmacy Director of Nursing

Moving and Handling Ailsa Hobkinson / Health & Safety Committee

Lead for Organisational Learning and Development

Director of HR

Resuscitation (Only BLS is reported currently)

David Bushby / Resuscitation Committee

Head of Multi-Professional Education

Director of HR

Safeguarding Adults

Nick Hale / Safeguarding Vulnerable Adults Committee

Director of Nursing Director of Nursing

Slips, Trips and Falls Kevin Ray/Health & Safety Committee


Director of Nursing


VTE Helen Yarranton / Sheena Patel/

Dr Richard Morgan/ Anna Bischler


Violence and Aggression Trevor Post/ Health & Safety Committee


Director of Nursing

Mandatory training requirements not relevant to all staff (NHSLA subjects highlighted)

Consent Patricia Small Director of Governance


Electronic Patient Record (health records) David Ball / Medical Records Committee

IT service desk Manager Director of IT

Medical Devices

Dr M Weston / Medical Devices Committee

Lead for Clinical Learning and Development

Director of HR

Investigations of Complaints, Claims Vivia Richards Director of Governance


Risk Management for Senior Managers Vivia Richards Director of Governance


NHSLA requirements for Maternity

Newborn Feeding Gillian Meldrum Deputy Head of Midwifery

Director of Nursing

Care of Women following op interventions Catherine Wilkins Head of Midwifery Director of Nursing

Early Recognition of Severely Ill pregnant Women Breedge Delaney

Deputy Head of Midwifery

Director of Nursing

Physical Exam of the Newborn Catherine Wilkins Head of Midwifery Director of Nursing

Continuous electronic foetal monitoring Charlotte Deans Deputy Head of Midwifery

Director of Nursing

Maternal Antenatal Screening Emma Bartlett Deputy Head of Midwifery

Director of Nursing

Maternal Resuscitation David Bushby Assist Dir Nursing Director of Nursing

Mental Health in Maternity Claudia Knightly Deputy Head of Midwifery

Director of Nursing

Midwifery Mentorship Lynne Baldock Lead Nurse for Education Director of HR

Management of Peri-neal trauma Claudine Dominey / Michaela Anderson

Deputy Head of Midwifery

Director of Nursing

Skills and Drills (maternity) Mr Shane Duffey Medical Director Medical Director

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