Mandatory and statutory training policy

1 Introduction

1.1 Rationale

Organisations require a systematic approach to ensuring that all staff receive relevant and timely mandatory and statutory risk management training and education.

Training and development helps an employee to achieve the organisational goals as well as their individual goals.

Training is also an essential control measure when managing risk associated with the provision of healthcare. A lack of training can be a contributory factor on incidents; therefore, if staff have been trained appropriately to undertake their duties the risks of an error or omission occurring can be reduced

Training is a learning process that involves the acquisition of knowledge, enhancement of skills and sometimes a changing of attitudes and behaviour leading to improved practice.

The aim of the training needs analysis (TNA) which supports this policy is to objectively identify the needs of all staff groups and the frequency of attendance. This will enable the trust to build a plan to deliver essential training opportunities.

2 Purpose

The purpose of this policy is to support the delivery of the trust’s risk management Strategy by setting out its arrangements for:

reviewing the training matrix to identify and document the mandatory risk management training requirements for all staff including volunteers and agency staff
implementing a systematic approach to mandatory and statutory training for all staff

3 Scope

This document applies to and is relevant across the list of topics defined as mandatory and statutory training and to the relevant staff identified in the via their matrix are required to attend each type of training.

4 Responsibilities, accountabilities and duties

4.1 Board of directors

The board of directors is responsible for ensuring that the trust consistently follows the principles of good governance applicable to NHS organisations. This includes the development of systems and processes for mandatory and statutory training.

4.2 Chief executive

The board of directors delegates to the chief executive the overall responsibility for effective risk management in the trust, meeting all statutory requirements and adhering to guidance issued.

The chief executive, in conjunction with the director of corporate assurance or board secretary will ensure that arrangements for delivery of risk management awareness training to all board members are in place.

4.3 Director of people and organisational development

The director of people and organisational development is the director designated with lead responsibility for learning and development, which includes mandatory and statutory training.

4.4 Directors

Directors have the delegated authority for ensuring that risk is managed appropriately in their area of responsibility.

They are responsible for the effective implementation of this policy and associated polices including induction, supervision and performance and development review (PDR), which provide a supporting framework for the planning, delivery and monitoring of mandatory and statutory training.

4.5 The head of learning and development

Reviewing staff matrix in conjunction with directors or associate nurse directors and heads of service as appropriate, identifying which staff groups are required to attend each type of training and the frequency of updates required.
Developing and disseminating an annual training plan, which draws together all the identified mandatory and statutory training.
Producing training compliance reports for the people focused care group meetings and for directors, associate nurse directors or heads of service. These will provide details of percentage compliance per service as well as names of attendees and non-attendees.
Following up non–attendance at training and liaising with trainers and managers as appropriate.
Developing proposals for any risk management training needs identified over and above those identified as mandatory and statutory training.
Producing an annual report and reporting on key risks and assurances for the people focussed care group meeting.
Liaising with other agencies that provide multi-agency programmes of training which trust staff access, for example, safeguarding children and safeguarding adults training, so that all staff training records are entered onto the trust’s electronic staff training record system to provide a comprehensive picture of training compliance.
Evaluating training and providing feedback to trainers so that training continues to be improved and remains fit for purpose. Management and coordination of the electronic staff training record system and the entry of all staff training records to the system.
The planning, delivery, monitoring, review and reporting of the trust’s Induction programme which includes key elements of mandatory and statutory training.
Reporting compliance with attendance at the trust’s Induction programme to the people focussed care group meeting. Following up non–attendance at the trust Induction programme with relevant managers.

4.6 People focussed care group meeting and POD

Approving the annual training plan based on the matrix evidence presented by the head of learning and development.
Monitoring mandatory and statutory training compliance by receiving monthly reports on key risks and assurances and an annual report.
Monitoring attendance at the trust’s induction programme which includes key elements of mandatory and statutory training.
The group reports to the board of directors through its minutes which are presented at each meeting.

4.7 Care group nurse directors, deputy care group directors and corporate heads of service

Identifying the priorities for mandatory and statutory training for their staff groups.
Monitoring that individual staff complete the relevant mandatory and statutory training and monitor the overall compliance rates for their service taking action as appropriate.
Discussing the reasons for non-attendance with their staff and re-booking them on the training.
Ensuring that persistent non-attendance is dealt with appropriately.
Identifying any risk management training needs over and above those identified as mandatory and statutory training, liaising with the head of learning and development for planning purposes.

4.8 Medical directorate manager

planning the induction and mandatory and statutory training for all new medical staff.
Working with the head of learning and development to review the matrix and training plan.
Ensuring that medical staff training records feed into the trust’s electronic staff training record system to provide a comprehensive picture of mandatory and statutory training compliance.
Discussing the reasons for non-attendance and re-booking staff on the training ensuring that persistent non-attendance is dealt with appropriately.

4.9 Director of corporate assurance and board secretary

Working with the head of learning and development to ensure MAST training needs are identified via the matrix for the board members.
Providing the training records for board members to the head of learning and development to be entered on to the electronic staff training record system to provide a comprehensive picture of mandatory and statutory training compliance.
In conjunction with the chief executive, to ensure that reasons for non-attendance are discussed and training is re-booked. Ensuring that persistent non-attendance is dealt with appropriately.

4.10 Trainers

Trainers who contribute to the delivery of mandatory and statutory training are responsible for completing accurate records of attendance at all training sessions and submitting these in a timely manner for entry to the learning and development service for entry on to the electronic staff training record system.

4.11 All staff

All staff have a responsibility for the management of risk, including legal duties under the Health and Safety at Work Act 1974, and all levels of management must understand and implement the trust’s risk management framework and associated policies and procedures.

Staff are responsible for completing the relevant mandatory and statutory training as identified with their manager.

The trust has a pay progression policy and procedure which has been developed in accordance with the agenda for change terms and conditions of service. The arrangements were introduced to ensure that in a patient centred health care system, employees are supported to develop and utilise the skills and behaviours required in a modern NHS organisation.

The intention of the pay progression procedure is to assist employees and managers to understand the requirements needed to progress through the Agenda for Change pay scale.

All staff have a responsibility to role model attitudes and behaviours that reflect the trust values (appendix B).

5 Procedure or implementation

5.1 Training requirements data collection table

A standard template is used to collect the information for the table which includes the following headings:

details of staff who will require each type of training
how often the training should be undertaken
frequency of updates required for each type of training
length of training
delivery method
Who will be responsible for the delivery of the training
Where the records of attendance are to be held

5.2 How action plans are developed to deliver the training identified

The head of learning and development together with relevant trainers will use ESR to identify what staff need to create a training plan for the year.
This will involve a gap analysis against the existing training provision and staff training resources.
A plan is then formulated based on this information and where gaps are identified alternative ways of delivery are identified and planned for such as e-learning, MS Teams delivery and leaflets.
Training is generally delivered by:
- full-time trust trainers, for example, Learning and Development team
- part-time trust trainers, for example, for manual handling and reducing restrictive intervention training
- trust leads whose role includes training, for example, health and safety, patient safety and Mental Capacity Act (MCA)
- staff in a range of clinical and non–clinical leadership roles using the CCAST clinical skills assessment

Training is generally delivered through:

the trust induction programme
local induction in-house courses
multi agency courses organised by local partner agencies, for example, safeguarding children and safeguarding adults training
externally commissioned training
on the job training
meetings, for example, conferences and team meetings
e-learning packages

5.3 How the trust records that all staff complete relevant training, in line with the matrix

The learning and development service manages and coordinates the electronic staff training record system and the entry of all staff training records, including those for board members.
Trainers are required to provide all training records to the learning and development service to be entered onto the electronic staff training record system. These are provided in an electronic or paper format and are required to be provided as soon as possible after the training has taken place.
Where agencies that provide multi agency programmes of training which trust staff access, for example, safeguarding children and safeguarding adults training, staff attending will be required to report attendance to the local ESR administrator so that attendance can be entered onto the system.

5.4 How the trust follows up those who do not complete relevant training programmes

The head of learning and development will:

follow up with care groups on a monthly basis non-attendance at those courses that form part of the induction such as manual handling induction, immediate life support induction, community life support induction, PMVA comprehensive 4 day induction, PMVA disengagement techniques, these courses have been selected as Induction courses comprise the majority of the DNA’s
follow up with managers in writing on a monthly basis persistent non–attendance at training managed by RDaSH academy, learning and development

Managers will:

make appropriate adjustments to the work of staff to allow training attendance, for staff who have not completed any required training
managers will discuss the reasons for non-attendance with their staff member and prompt the staff member to rebook themselves onto the training

5.5 Action to be taken in the event of persistent non-attendance

Managers will ensure that persistent non-attendance is dealt with appropriately:

this will involve a formal documented discussion with the member of staff concerned, to ensure the reasons are fully understood and where the requirements to attend training are made explicit with timescales for completion, the values and behaviours framework is available at appendix B to assist with these discussions
the manager will risk assess the consequences of training not being completed and may need to take action
following non-attendance on three separate occasions, at any training managed by RDaSH academy, learning and development within a twelve month period, the manager will escalate the situation and involve the human resources department to undertake appropriate disciplinary action

5.6 How risk management awareness training is delivered to board members and senior managers in line with the matrix

Both Board members and senior managers are included as groups within the matrix and training is delivered to them as identified for all staff, via the trust Induction and in-house courses.
Any additional needs identified will be planned and delivered as required.

6 Training implications

There are no specific training needs in relation to this policy. All staff both as recipients of training and those with responsibility for commissioning, developing, organising, delivering, monitoring and recording mandatory and statutory training will need to be familiar with its contents.

The training needs analysis (TNA) for the PMVA policy, which is part of MAST training, can be found in the trust’s mandatory risk management training policy.

6.1 Employee groups requiring training

How often should this be undertaken:
Length of training:
Delivery method:
Training delivered by whom:
Where are the records of attendance held:

As a trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through a variety of means such as:

all user emails for urgent messages
one to one meetings and supervision
continuous professional development sessions
posters
daily email (sent Monday to Friday)
practice development days
group supervision
special meetings
intranet
team meetings
training sessions
local induction

7 Monitoring arrangements

7.1 MAST training matrix for all care groups

How: ESR.
Who by: Head of learning and development.
Reported to: People focus care group meetings.
Frequency: Determined by statutory or legislative changes, so in line with national requirements.

7.2 Annual training plan reflecting the MAST training matrix

How: Included in the care group dashboard.
Who by: Presented by the care group ER representative.
Reported to: People focussed care group meetings, POD committee as part of workforce dashboard.
Frequency: Monthly and bi-monthly.

7.3 MAST non-compliance

How: Email notification.
Who by: System generated.
Reported to: Individual and line manager.
Frequency: 3 months prior to competence expiry.

7.4 Persistent DNA’s

How: Flagged in supervision or pay step progression.
Who by: Line managers.
Reported to: Focussed care group meetings.
Frequency: Monthly.

7.5 Attendance for MAST recorded on ESR for board members

How: Report.
Who by: Head of education or board secretary.
Reported to: Chief executive and chairman.
Frequency: Annual.

7.6 Non-attendance follow up for board members

How: Report.
Who by: Head of education or board secretary.
Reported to: Chief executive and chairman.
Frequency: Annual.

8 Equality impact assessment screening

The completed equality Impact assessment for this policy has been published on this policy’s webpage on the trust policy library or archive website. Link to overarching EIA.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act 2005

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005)to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

Where English is not the preferred language of the patient or service user, using an interpreting service should enhance the assessment of Mental Capacity.

9 Links to any other associated documents

The contents of this policy are to be read in conjunction with the following trust policies:

10 References

11 Appendices

11.1 Appendix A Definitions and explanation of terms used

Definitions
Term	Definition
Training requirements data collection table	The training requirements data collection table is a ‘breakdown, usually presented in the form of a spreadsheet or table, which contains as a minimum: all staff groups all training required by each group the frequency of training required by each group This may also include further details such as who will provide the training, the specific training package to be used, etc.’ The training requirements data collection table identifies topics which are mandatory and statutory requirements within the trust. Compliance with these requirements delivers risk management. This list of topics defined is not intended to be exhaustive or static. The need for additional training may be identified and included as risk management policy and practice is reviewed, to support a continuous process of improvement and organisational learning
Senior managers	For the purpose of this policy, senior managers are defined as clinical and non clinical managers in band 8 and above (excluding board members)
Board of directors	Members of the executive and non-executive board of directors

11.2 Appendix B Values and behaviour framework

11.2.1 Passionate

We work hard to deliver a quality service.
We are determined to do what’s right for people.
We are positive in all that we do.
We endeavour to be our best through personal development.
We do our best to make a positive difference to people.

11.2.2 Reliable

We follow through on what we say we will do.
We take responsibility for things we can do something about.
We take ownership to know and follow best practice.
We are accessible whenever possible.
We turn up on time and complete tasks in the time agreed.

11.2.3 Caring and safe

We promote equality, diversity and inclusion.
We take a person-centred approach.
We take time to listen with empathy and compassion.
We introduce ourselves.
We make sure we keep people safe and speak up when something is wrong.

11.2.4 Open

We include people in the decisions that affect them and keep them informed.
We give and receive purposeful feedback.
We acknowledge our own biases and learn from others perspectives.
We celebrate our successes and learn together from our mistakes.
We are honest and accountable taking responsibility for our actions.

11.2.5 Supportive

We encourage good physical and mental health including promoting a healthy work life balance.
We appreciate and respect other people’s input and ideas.
We value our patients, their families, their carers and each other.
We work together as #onerdash team.
We help each other to do the best job we can.

11.2.6 Progressive

We work together for continuous improvement.
We seek out and share information, knowledge, and experiences.
We are adaptable and flexible- open to innovation and change.
We strive for excellence through identifying and testing new ways of working.
We take responsibility to share and learn from and about each other.

11.2 Appendix C Covid 19 temporary MAST changes

As an organisation we continually strive to ensure our staff receive high quality training, and to ensure safety in the workplace is maintained during the COVID-19 outbreak the trust approach to mandatory and statutory training (MAST) has been streamlined in line with government guidance. Staff will undertake their mandatory training completing e-learning modules, and by attending classroom sessions only for specific subject areas, this will support social distancing measures and ensure the maximisation of safe staffing across all areas.

In order to achieve this, the minimum training for clinical areas we would expect for business-critical areas is as follows:

new starters will receive the trust induction booklet through the post as corporate induction day is suspended, this includes all level 1 subject requirements for all staff in leaflet form, the trust is in the process of creating an electronic version of the induction booklet
e-learning for all new starters in the following subjects can be completed prior to starting in the trust:

- fire safety
- health safety and security
- infection prevention and control (level 2)
- preventing radicalisation (PREVENT) (level 3)
- equality, diversity and human rights
- information governance and data Security
face to face training is booked according to areas of work and will consist of:
- half day life support
- half day manual handling
- 1-day PMVA disengagement techniques or 4 days PMVA comprehensive

The above changes to the MAST provision are valid for the period of the pandemic and have had the agreement of the trust executive team via the gold command structure.

In order to provide supplementary non-MAST training for staff throughout the pandemic the Learning and Development team have developed a repository of reputable Covid 19 upskilling courses.

These courses are accessible via the learning and development intranet webpages, these are reviewed regularly and can be accessed by all staff and are additional to MAST requirements.

Document control

Version: 11.1.
Unique reference number: 307.
Approved by: Corporate policy approval group.
Date approved: 25 January 2024.
Name of originator or author: Deputy manager and lead facilitator.
Name of responsible individual: Head of learning and development.
Date issued: 26 January 2024.
Review date: December 2024.
Target audience: All staff, including volunteers and agency staff, both as recipients of training and those with responsibility for commissioning, developing, organising, delivering, monitoring and recording mandatory and statutory training.

Page last reviewed: April 15, 2024
Next review due: April 15, 2025

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