Statutory and Mandatory training policy FINAL - Statutory and...Mandatory training required will be dependent on role and location and will come under two broad categories: Trust wide

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North East Ambulance Service

Managing CapabilityStatutory and Mandatory Training Policy

Document Profile Box

Document Reference: Version: DRAFT 1 Ratified by: Trust Board Date ratified: Name of originator/author: Name of responsible committee/individual:

Chris HarrisonJulie Cowen, Director of HR &Head of ODWorkforce Development

Date issued: Review date: March 2011 Target audience: All Staff Document owner: Chris Harrison, Director of HR &

ODDeborah Fairbotham, Head of Non Clinical Education

Authorised signatory: As above

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Content

Paragraph Title Page

1 Introduction 3

2 Policy statement and Scope 3

3 Definitions and Responsibilities 3

4 Informal Procedure 4

5 Formal Procedure 5

6 Appeal Procedure 7

7 Equality and Diversity Statement 7

8 Consultation, approval and ratification process 7

9 Dissemination and implementation 7

10 Monitoring compliance with this policy 8

Appendices

A Authority to Act 8


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B Stage 3 meeting procedure 9

C Appeal meeting procedure 10

D Invite to Stage 1 11

E Invite to Stage 2 12

F Outcome of Stage 1 or 2 13

G Template Action Plan 14

H Invite to Stage 3 15

I Outcome of Stage 3 16

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Content

1. Introduction .......................................................................................................... 5

2. Policy Statement and Scope ................................................................................ 6

3. Responsibilities .................................................................................................... 7

3.1 Responsibility of the individual employee ...................................................... 7

3.2 Responsibility of the Manager ....................................................................... 8

3.3 Responsibility of the Trainer .......................................................................... 9

3.4 ......................................................................................................................... 10

Responsibility of the Workforce Development Department ................................... 10

3.5 Organisational Responsibility ...................................................................... 11

4. Statutory Training .............................................................................................. 12

5. Mandatory Requirements .................................................................................. 13

6. Additional Clinical Skills update ......................................................................... 17

7. Equality and Diversity Statement ....................................................................... 18

8. Related Documents ........................................................................................... 18

9. Consultation, Approval and Ratification Process ............................................... 18

10. Dissemination and Implementation ................................................................ 19

11. Monitoring Compliance with this policy ........................................................... 19

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1. Introduction

The North East Ambulance Service NHS Trust (NEAS) recognises that Statutory &

Mandatory training is of vital importance to underpin the services it delivers to

patients. It also fulfils legal requirements set out by the HSE (Health and Safety

Executive) and assists in providing a safe environment in the workplace. It is

committed to ensuring that adequate provision is made for all staff to undertake this

training and for clinical staff to maintain and improve their professional competence

ensuring the best possible service delivery.

1.1 All employees have a responsibility to achieve a satisfactory level of

performance and to carry out their duties to the standards required. Whilst it is

recognised that the vast majority of employees meet or exceed the expectations of their

roles, some problems do arise. This document is intended to provide a fair, supportive

and consistent framework for dealing with employees who are not achieving the

required standards.

1.2 Capability refers to an individual’s ability to achieve these required standards,

consideration has to be given to the reasons why an employee may be failing to do so.

A distinction needs to be made between what is and what is not within an employees

control prior to implementing the formal capability procedure. For example a situation

which may not be of the employee's own making, such as long-term sickness,

underlying work problems or personal circumstances outside of work may be more

appropriately addressed through the attendance management policy. Alternatively if

performance is deemed to be attributed to an employees conduct rather than their

capability it may be more appropriate to address the issues under the Disciplinary

Policy. Making this distinction is sometimes not clear cut and requires careful thought

and sensitivity. Managers are strongly advised when handling capability cases to speak

to a member of the Human Resource team at the earliest opportunity.

1.3 It is important that line managers are able to be specific in relating poor

performance to specific standards, for example in job descriptions, training manuals,

protocols or KSF documentation. These standards will help to explain dissatisfaction


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with the employee’s performance and also assist the employee in understanding

how performance can be improved and how it will be measured. A lack of ‘capability’

to perform the duties of a post to a satisfactory standard as detailed in protocols,

procedures and codes of conduct will normally be established by reference to skill,

aptitude, health or any other physical or mental quality.

2. Policy Statement and Scope

2. 2.1 The aim of this policy to ensure all staff and their managers are aware

of their responsibility in relation to Statutory and Mandatory training. By doing so the

quality of services offered will be maintained and the chances of staff making

erroneous decisions, which may affect personal, patient, staff or visitor safety, will be

reduced. Failure to comply with these requirements may increase the risk of

litigation against the individual and the Trust and will assist in improving the health,

safety and welfare of all employees and users of Trust services.

2.2 This policy applies to all employees, including volunteers, employed by

(NEAS). Staff not directly employed by the Trust, such as agency and contracted

staff should undergo similar training activities as provided by their direct employer to

a minimum legal standard. The Trust will only provide any additional mandatory

units applicable only to this Trust.

2.3 Definitions

2.3.1 Statutory Training

The training is required by legislation or statute regardless of the

employing bodies own rules and regulations. The Trust is required to ensure

statutory training takes place in line with existing and changing regulations

authorised by statute. This applies to all staff, in all roles and locations.

2.3.2 Mandatory Training

Mandatory is defined by the Trust as training it considers essential to

the performance of specific jobs in the organisation to maintain the quality of



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services it wishes to provide for the population of the North East of England.

Mandatory training required will be dependent on role and location and will come

under two broad categories:

Trust wide For all or the majority of staff, across the Trust.

Local: For specific staff groups, departments, functions or professions.

2.1 The aims of this policy are to improve the level of service provided

by maintaining reducing required standards of work. Poor performance

disrupts service provision, increase demands on employees at work and

result in extra cost to the Trust to maintain services. It is the intention of

the Trust that wherever possible managing capability will be dealt with in

a sensitive and supportive manner to the mutual benefit of the employee

and the Trust. This Trust is committed to promoting the health, safety

and welfare of its employees

2.2 This policy applies to all employees of the North East Ambulance

Service NHS Trust who have more than 12 months service.

3. Responsibilities

3.

3.1 3.1 Responsibility of the individual employee

• To attend statutory and mandatory training provided by the Trust on an annual

basis. (The Training year is concurrent with the financial year) Initial

attendance should be within the first month of employment wherever possible.

In following years statutory and mandatory training should be prioritised over

all over training.

• Complete any pre-course work as supplied by the training team before

attendance on the course.


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• Attend the course as scheduled. If unable to attend the non attendance

procedure as laid out in the Education, Learning and Development policy

should be used.

• To engage with the trainer during the courses and undertake practical

assessments within the course unless physically unable to do so.

• Ensure that eKSF records are updated before attendance and completed after

attendance.

• Keep a personal record (Issued certificate) of the development undertaken if

required by professional body Continuing Professional Development. (CPD)

• Be aware of the job descriptions, training manuals, protocols and KSF outline

for the role.

• Follow the training given.

• Approach their manager should they feel they require training or support with

any aspect of their role.

• Attend review meetings, training and occupational health appointments as

required.

3.2 3.2 Responsibility of the Manager

• To ensure that all staff they are responsible for attend statutory and

mandatory training relevant to their job role on an annual basis.

• To ensure that attendance is recorded and updated on the eKSF system and

included on individual Personal Development Plans (PDP) and departmental

training plans.

• To investigate non attendance, or late cancellation, when notified by training

administration and take disciplinary action when appropriate. (see Education,

Learning and Development Policy) The Manager should also ensure that the

staff member is re-booked as soon as possible and within the training year.

• Arrange date of attendance with member of staff, using the booking

procedure.

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• To discuss absence during the course in the scheduled return to work

interview and re-book employee as soon as it practicable.

3.3 Responsibility of the Trainer

• Follow the agreed planning and implementation schedule

• To provide quality training in accordance with Trust lesson plans.

• To ensure learners understanding of all subjects through discussion, testing,

observance of practical skills and by any other appropriate method.

• To ensure that attendance is recorded and attendance sheets passed to

training administration.

• Ensure line managers are notified of employees absence from course, within

two hours of start time, in accordance with agreed standards

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• 3.4 Ensure that the job descriptions, training manuals, protocols and

KSF outlines are kept up to date and are available for all employees.

• Ensure that training is arranged in a timely manner and accessible for all

employees.

• Ensure that members of staff with less than 12 months in the role are

managed under the probationary period policy.

• Devise and implement clear action plans addressing all factors

identified as contributing to poor performance.

• Provide clear constructive feedback on performance.

• Arrange and undertake reviews of any action plans put in place and

maintain adequate records.

• Consider whether there are underlying reasons contributing to poor

performance and whether occupational health support is appropriate.

• Where an employee has been referred to Occupational Health, ensure

the employee fully understands with the reason for their referral, showing

empathy where required.

• Liaise with HR at an early stage of using the capability policy.

3.3 Responsibility of the Human ResourcesWorkforce Development

Department

• Will provide adequate training places for all employees of the Trust. Dates

will be allocated in conjunction with operational requirements.

• Provide any pre-course training material at least two weeks prior to the

original booked date, any replacement material may be recharged to the

students department.

• Record attendance on each course and immediately inform managers of non-

attendance.








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• Ensure that the most up to date training is provided in line with legislative

changes. The content of Clinical Skills days will be updated each April to

ensure skill levels across the clinical workforce are of a similar standard.

• Ensure that the most appropriate and cost effective training methods are

used, this may include, but is not limited to, written, taught, e-learning and

podcast lessons.

• Ensure managers are made aware of any developments in statutory and

mandatory training in a timely manner.

• Provide advice and support to employees and line Managers in respect of this

policy.

• Support line Managers to ensure that appropriate action is taken where

performance falls below the acceptable standards.

• Ensure all correspondence relating to attendance management issues is kept

on the personal file.

• Ensure consistency of practice across the Trust with regard to this policy

through monitoring of Key Performance Indicators.

• Liaise with the Occupational Health Department.

• Support any redeployment of staff in conjunction with managers where

deemed applicable.

3.5 Organisational Responsibility

• To provide paid protected training time for any statutory and mandatory

training.

3.4• Support the development of new and appropriate methods of delivery

and Responsibility of the Occupational Health Departmentadvise staff of

legislative changes.

• Undertake, pre-employment health screening consisting of full assessment of

past and present medical and any relevant employment history.

• Maintain OH records on all employees

• Pro-active health surveillance/monitoring of employees as per Health and

Safety legislation


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• Work actively with managers to tackle performance issues related to health /

disability concerns and advise on external organisations that can provide advice on

workplace adjustments that can be considered.

• Access to confidential counselling services to which staff can self refer

• Health screening e.g vision, hearing

• Self referral service for staff who wish to refer themselves for an OH

appointment

44. Informal ProcedureStatutory Training

4.1 The Trust is required to ensure that all statutory requirements are in place

and adhered to by all staff. This includes:

• Ensuring the quality, content and frequency of training provided.

• Maintaining adequate records of staff training.

4.2 The following training is statutory for all staff, it will be tailored to the work

environment of the staff member as appropriate, it includes but is not limited to:

5• Workplace Health & Safety

o RIDDOR

o COSHH

• Risk Assessment

6• General Manual Handling

o Slips trips and falls

o Moving and handling

• Fire Safety

• VDE (Visual Display Equipment)

7• Mental Capacity Awareness

o Safeguarding adults

8• Security and Confidentiality

These requirements may change at any time due to legislative developments and

additional development will be implemented in the most timely and cost effective

manner.

4.1 Informal discussion





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The informal approach is aimed at bringing the manager’s initial

concerns to the attention of the employee, exploring the reasons behind

poor performance and considering whether alternative policies are more

applicable. The manager should consider the objective factual

indications such as observation, feedback, factual data and have an

informal discussion with the employee to establish the problem and

whether there are underlying problems that are contributing to the poor

performance and agree a solution / action plan.

4.2 Possible Outcomes

• Continue with the informal approach and review the progress

• Take action or provide support through a more appropriate policy

or procedure

• Review the duties, responsibilities and other aspects of the job

• Provide appropriate training

• By agreement – investigating the possibilities of redeployment or

transfer to alternative post with the department.

• Proceed to the first stage of formal procedure

95. Formal ProcedureMandatory Requirements

5.1 The following training is mandatory for all staff, however it will be tailored to

the general working environment of the individual, it includes but is not limited to:

• Communication

• Equality & Diversity

o Bullying and Harassment

• Fraud & Whistle Blowing

• Basic Resuscitation

• Infection Control





















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o Hand Hygiene

o Control and prevention

• Other subjects may be mandatory dependant on work area, normally clinical

staff. These include but are not limited to:

• Conflict resolution

o Violence and aggression

• Child protection (level dependant on job role)

• Patient safety

o Health Record Keeping

• Personal Safety

• Specific conditions

o Stroke Care

o Obstetric Care

o Paediatric Care

o Inoculation Incident Training

• Investigation of incidents, Complaints and Claims Training (Managers Only,

all areas)

5.1 Stage 1

5.1.1 A formal meeting should be arranged by the Manager with the employee to

discuss their poor performance. Human Resources should be consulted for advice

and attendance where necessary. This meeting should be notified to the employee in

writing, giving 7 calendar days notice and stating the reason for the meeting.

Employees must be informed of the right to be accompanied by a recognised trade

union representative, or an appropriate work colleague throughout this procedure. It

is the employee’s responsibility to arrange for appropriate representation, only one

alternative date will be offered. Thereafter the meeting may go ahead in the

absence of the employee or their representative.

5.1.2 Staff can be offered the opportunity to attend meetings on rest days, where

available.




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5.1.3 Template letters can be found in Appendices. The purpose of these

documents are to help the line manager follow a process during and at the end of the

meeting.

5.1.4 The purpose of the meeting

To formally raise the concerns about the poor performance and establish where the

employee has fallen short of the standards required by the KSF, job description etc.

Consideration should be given to underlying reasons out of the employee’s control

which may be contributing to the poor performance and if so what action could be

taken to remedy the situation. The impact on other employees and the Trust should

also be discussed. Explore possible solutions and provide an opportunity for the

employee to respond and comment.

5.1.5 Possible outcomes of the meeting

The Human Resources department must be consulted at every stage in the process

and the discussion and outcome must be confirmed to employee in writing. Template

letters can be found in the appendices. A mixture of outcome may be applicable.

• To issue a formal stage 1 warning – the right to appeal should also be given

• To instigate an action plan and a review period over a defined timescale

during which performance must improve to the standards stipulated. The length of

the action plan should reflect the nature of the improvement required.

• To consider adaptations to working practices/conditions

• By agreement – investigating the possibilities of redeployment or transfer to

alternative post with the department.

• Provide appropriate training

• Outline the possible action to be taken should performance not improve to an

acceptable level.

5.1.6 Reviewing the action plan

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The employee should be requested to attend review meetings during their action

plan period. Where there has been no significant improvement the outcome of these

meetings, could be to either extend the period of review or to proceed to a stage 2

meeting.

5.2 Stage 2

9.1.1 Where there has been no significant improvement based on the standards

and action plan agreed at Stage 1 a Stage 2 meeting should be arranged by the

manger. The procedure for arranging this should follow that outlined in stage 1 and

the discussion and outcome should follow that outlined in 5.1.4 and 5.1.5. This

should also be confirmed in writing using the template letters in the appendices.

9.1.2 The possible outcomes should be considered as given in 5.1.5, if a warning is

issued at this stage this will be a stage 2 warning and employees should be made

aware that if there is no significant improvement in performance this may result in

termination of their contract of employment.

5.2.2 If after this warning, there is no significant improvement, the Human

Resources Team must be consulted as to whether it is appropriate, at this stage, to

convene a final meeting known as Stage 3, with the employee and their Trade Union

representative or colleague to consider termination of employment. This could result

in their contract of employment being terminated on the grounds of capability.

5.3 Stage 3 – Potential Termination of Employment

5.3.1 The meeting should be chaired by a manager with the appropriate authority to

act (Appendix A) together with a Human Resources representative following the

procedure highlighted in section 5.1.1 and consider the following:-

• details of meetings previously held

• prospect of an improvement in performance

• Any relevant mitigating information from the employee and their

representative


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5.3.2 If no new mitigating circumstances are presented and the Chairperson has

fully considered the employee’s length of service, the effect of their poor

performance on the service, and possible redeployment, the employee’s contract

may be terminated.

5.3.3 The Chairperson must give confirmation of the termination of employment in

writing within 7 calender days of the meeting. This must include the notification to the

employee of their right to appeal.

5.3.4 If it is felt that there are new mitigating circumstances and there is a good

reason why these have not been raised by the employee at an earlier stage, then

consideration may be given to a further period of support and monitoring. However if

there is no improvement during that period the employee will again be invited to a

meeting where the Trust will again consider termination of employment due to poor

performance. Again this must be confirmed in writing by the Chairperson within 7

calender days of the meeting.

66. Appeal ProcedureAdditional Clinical Skills update

6.1

6.1 Any appeal against a warning or dismissal should be sent in writing to the

Human Resources Department within 14 calendar days of the date of the letter

clearly setting out the reasons for appeal.

6.1 The employee will be offered the right to be accompanied by a Trade Union

representative or appropriate work colleague at any meeting organised to consider

the appeal.

An appeal hearing will be set up following the procedure laid out in the appendices.

The outcome of the appeal hearing is final and there is no further right to

appeal.Following the combined statutory and mandatory skills update all clinical staff

will undertake an annual one day skills update. Content of this course will be

authorised by the Head of Clinical Education on an annual basis. If any member of

clinical staff is unable to attend in any April to April period eg due to long term


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sickness or secondment it will be the responsibility of the manager to ensure that

they notify the Head of Clinical development as soon as possible to ensure that the

staff member does not miss the training delivered in that year.

7. 7. Equality and Diversity Statement

7.1 The Trust is committed to providing equality of opportunity, not only in its

employment practices but also in the services for which it is responsible. As such,

this document has been screened, and if necessary an Equality Impact Assessment

has been carried out on this document, to identify any potential discriminatory

impact. If relevant, recommendations from the assessment have been incorporated

into the document and have been considered by the approving committee. The Trust

also values and respects the diversity of its employees and the communities it

serves. In applying this policy, the Trust will have due regard for the need to:

• Eliminate unlawful discrimination

• Promote equality of opportunity

• Provide for good relations between people of diverse groups

78. Related Documents

• Education, Disability Equality Policy (QSSD )Learning and Development

policy

Employee Friendly Policy (QSSD )

Disciplinary Policy(QSSD )

• Probationary Policy (QSSD )Induction policy

• Statutory and Mandatory booking procedure

9. 8. Consultation, Approval and Ratification

Process

9.1 Consultation Process

This policy has been discussed with the management representatives and staff side

representatives during the development process.









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9.2 Policy Approval Process

This policy has been submitted to the Policy Review Group for approval.

9.3 Ratification Process

This policy has been approved by the Policy Review group and submitted to the

Trust Board and JCC for ratification.

910. Dissemination and Implementation

10.1 Dissemination

Once ratified this policy will be added to the Document Quality Control System and

added to the Intranet site to which all staff have access. Earlier versions of the

document will be archived in the quality system.

10.2 Implementation of Procedure

All managers and team leaders will advised of the policy via email and on policy

update.ural

Documents

Information about this policy will be added to Statutory and Mandatory

Training which is delivered to all staff on an annual basis.

11. 10. MMonitoring Compliance with this policy

11.1 This policy will be reviewed twelve monthly or earlier if required by The Trust

Board and The Assurance Committee. The effectiveness of the policy will be

monitored on regular basis via the trusts Executive TeamExecutive Team. Key

performance indicators will be monitored by analysing data received from the HR

team against agreed trust/national targets.

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20

Address

Tel Number

DATE

Private and Confidential

NAME

ADDRESS

Dear NAME,

Ref: Stage 3 meeting - Outcome

Thank you for attending the meeting held on (insert date) in the

presence of (insert attendees and job titles). I write to confirm the

outcome.

We discussed the previous meetings held under the managing

capability policy and the progress you have made in relation to the

action plans and targets set.

(INSERT ANY FURTHER DETAIL OF ANY CONVERSATION YOU HAD AT

THIS POINT REGARDING THE ABOVE)

Decision to terminate employment (use this section and delete this line)

I confirm that the decision was taken to terminate your contract of

employment on the grounds of capability for failing to meet the

standards required for your job role.

In accordance with current legislation, you are entitled to (insert

number) weeks notice and you will choose either be expected to work

this notice period OR be paid in lieu of notice. This makes your

termination date (insert date) on.


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21

The termination of your contract of employment is a dismissal, and you

have the right of appeal to the Trust against this decision. Should you

wish to execute this right, you should submit your appeal in writing to

the Human Resources Department, at (address), clearly stating your

reasons for appeal within 14 calender days of the date of this letter.

Decision not to terminate (use this section and delete this line)

You submitted additional mitigating circumstances that the panel has

taken into consideration and as such your contract will not be

terminated at this stage. Your action plan review has been extended for

a further (insert number) months and your progress will be reviewed

during this period.

Please be aware that should you fail to achieve the standards required

you may be invited to a meeting where the Trust will again consider

termination of employment due to poor performance.

Yours sincerely

(insert name)

(Insert Title)

CC: Line Manager & Persona





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