Royal Liverpool and Broadgreen University NHS Hospital Trusts
Trust Operational Policy
Human Resources and Organisational Development Services
Induction and Mandatory Training Policy
Policy Reference: 4139
0
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Document Title
Author/Contact
Document Path & Filename
Document Control
Induction and Mandatory Training Policy
Stella Clayton
EQMS Document Management System
Document Reference
4139
Document Impact Assessed
Yes/No
Version
3
Status
Ratified
Publication Date
31st August 2011
Review Date
30th August 2013
Approved by (Executive)
Diane Wake
Date: 17th May 2011
Ratified by (Relevant Group)
NHSLA Working
Group
Date: 17th May 2011
Date: June 2010
Distribution:
Royal Liverpool and Broadgreen University Hospitals NHS Trust-intranet
Please note that the Intranet version of this document is the only version that is
maintained.
Any printed copies must therefore be viewed as “uncontrolled” and as such, may not
necessarily contain the latest updates and amendments.
Document History
Version
0.1
Date
14 June 2010
Comments
0.2
2 August 2010
0.3
1.2
3 November
2010
6 December
2010
April 2011
1.3
April 2011
1.4
May 2011
2.0
May 2011
3.0
August 2011
Amendments following comments from
Mandatory Training Group and Directorate
Managers
Amendments following comments from
Mandatory Training Group
Ratified by Governance and Risk Management
Committee
Amendments following comments from Risk
Management/Mandatory Training Group/
Amendments following Mandatory Training
Working Group
Amendments following comments from Subject
Experts
Amendments following further comments from
Risk Management
Strengthened policy in order to make clearer
process to follow (comments from NHSLA
Assessor and Monitor Assessment)
1.0
1
Merging of Induction and Mandatory Training
Policies
Author
Stella Clayton
Stella Clayton
Stella Clayton
Stella Clayton
Susan Jones
Susan Jones
Susan Jones
Susan Jones
Helen Ballinger
Stella Clayton
Susan Jones
Debra Bradley
Jo Charing
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Review Process Prior to Ratification:
Name of Group/Department/Specialist Committee
Mandatory Training Group
Subject Experts
Date
April 2011
May 2011
Table of Contents
HEADING
Control Sheet
1.0
Introduction
1.1
Equality and Diversity
2.0
Objectives
Page Number
3
3
4
3.0
Scope of Policy
4
4.0
Policy
5
4.1
4.2
4.3
4.4
4.5
4.6
5.0
Definitions
Corporate Trust Induction
Local Induction
Mandatory Training
4.4.1 Required Attendance at Mandatory Training
Process for Developing the Training Needs Analysis
Process for Developing an Annual Training Prospectus
5
5
7
8
9
10
11
Roles and Responsibilities
11
5.1 Mandatory Training Group
5.2 Director of HR & OD
5.3 Deputy Director of OD
5.4 HR Business Partners
5.5 Risk Manager
5.6 Recruitment Services
5.7 Learning & Development Services
5.8 Post Graduate Education Centre
5.9 Directorate Managers
5.10 Line Managers
5.11 All Staff
11
12
12
12
12
12
12
13
13
13
14
Associated Documentation and References
14
6.1 Legal Requirements, National Standards & Guidance
6.2 Documentation
14
15
7.0
Training
15
8.0
Monitoring and Audit
15
8.1
8.2
8.3
8.4
8.5
8.6
17
17
18
18
18
18
6.0
Recording and Monitoring of Equality and Diversity
Recording & Reporting
Reporting process
Document Control
Register/Library of Procedural Documents
Process for retrieving archived Documents
9.0
Consultation
19
10.0
Approval & Ratification
19
APPENDICES
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
Appendix 1 – Corporate Trust Induction Programme
Appendix 2 – Local Induction Workbook
Appendix 3 – Local Induction Checklist
Appendix 4 – Rapid Induction Pack (Locum/Agency)
Appendix 5 – F1 Induction Programme
Appendix 6 – ST 1 – 5 Induction Programme
Appendix 7 – F1 Teaching Programme
Appendix 8 – Mandatory Training Matrix
Appendix 9 – Core Skills Update programme
Appendix 10 – Equality Impact Assessment Tool
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
1.0
Introduction
Starting a new job can be a demanding and pressured experience. Apart from the obvious
challenge of tackling new tasks, there is also the need to become accustomed to a new
organisation, a new environment and new colleagues.
All new employees must attend Corporate Induction during their first week, which includes
all of the mandatory, legal, health and safety training they need to boost confidence and
smooth their transition into employment within the organisation. Having spent time and
effort in recruiting the right person, a comprehensive, relevant Induction is essential in
ensuring that the successful applicant becomes an effective, motivated member of staff in
the shortest time possible.
Attending a Corporate Trust Induction and completing Local Induction is only the first part
of a continuing process of learning. Royal Liverpool and Broadgreen University Hospitals
NHS Trust (RLBUHT) must ensure that all staff are trained and kept up to date with
legislation, and recommendations and guidance appropriate to their role starting with
recruitment and throughout their career at RLBUHT. This type of training is “Mandatory” training deemed as essential by RLBUHT for all staff, or for specific groups of staff
according to their job role. Mandatory Training includes health and safety legislation,
healthcare professional standards and other relevant guidance. This policy covers the
requirements of both Induction and Mandatory Training, and is important for the safety of
our staff, our patients’, relatives and carers, and all those visiting our premises.
Delivery of a comprehensive Corporate Trust Induction and Local Induction indicates a
high level of commitment to new employees, ensuring that they feel confident and
competent in delivery of high quality care and services. Insistence upon completion of
relevant mandatory training demonstrates the Trusts commitment to a culture of staff
development, patient safety, high quality clinical care and support services.
1.1
Equality and Diversity
The Trust is committed to an environment that promotes equality and embraces diversity
as an employer and in provision of services. It will adhere to legal and performance
requirements ensuring that equality & diversity principles are in policies, procedures and
processes. This policy is implemented with due regard to this commitment.
To ensure that the implementation of this policy does not have an adverse impact in
response to the requirements of the Race Relations (Amendment Act), the Disability
Discrimination Act 2005, and the Equality Act 2006 this policy has been screened for
relevance during the policy development process and a full impact assessment conducted
where necessary prior to consultation. The Trust will take remedial action when necessary
to address any unexpected or unwarranted disparities and monitor practice to ensure that
this policy is fairly implemented.
This policy and procedure can be made available in alternative formats on request
including large print, Braille, moon, audio, and different languages. To arrange this
please refer to the Trust translation and interpretation policy in the first instance.
The Trust will endeavour to make reasonable adjustments to accommodate any employee
with particular equality and diversity requirements in implementing this policy and
procedure. This may include accessibility of venues, providing translation, arranging an
interpreter, extending timeframes to enable translation to be undertaken, or assistance
with formulating any written parts to Induction and Mandatory training requirements.
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
2.0
Objectives
The delivery of high quality care for patients is at the heart of what we do, with the
minimisation of risk being an integral part. This policy supports the Trust in this aim by
setting out health and safety training expectations for all managers and staff within the
Trust, including those who work in partnership through contracts, secondment, or as a
volunteer. It is expected that all managers realise the importance of adhering to this
policy, and implement it rigorously when recruiting, and when supporting staff and others
to develop. In so doing, the Trust and its staff will improve the quality of patient
care/services, and reduce risks for all who come into contact with the Trust.
5 steps to success - RLBUHT is committed to ensuring that:
1. All managers adhere to set start dates for recruitment,
2. All staff complete the Corporate Trust Induction Programme during their first week.
3. Staff complete the standardised Local Induction Workbook within the first month,
(including staff who internally transfer/get promoted).
4. All staff receive Mandatory Training according to their role, with a minimum of 80%
attendance/compliance.
5. Recording, reporting and monitoring of attendance against agreed targets takes place
and action is taken where there is a shortfall against agreed target.
Measures of Success
 Corporate Trust Induction, Local Induction, and Mandatory Training is compliant with
legislation/recommendations, the NHS North West Core Skills Framework , and
provided in sufficient capacity to meet need, including flexible provision where
appropriate e.g. e learning, work based learning.
 Clear Mandatory Training expectations are set out by job role,
 Staff can access Mandatory training according to equality and diversity guidelines.
 Managers accept responsibility for ensuring that staff complete mandatory training.
 Staff understand their mandatory training requirements, and take personal
responsibility for fulfilling them.
 Staff are given the time to attend Induction and Mandatory training as part of the
working week, paid time, or as time paid back in lieu.
 Staff complete their required mandatory training, or have a booked place, before any
other training/study leave is approved.
 Mandatory training attendance and non attendance is monitored and reported, and
action taken to address shortfalls.
 Managerial action is taken where staff fail to attend, and/or do not complete their
required training and there are no mitigating circumstances, e.g. being prevented from
attending due to emergencies in the workplace.
 Managerial action is also taken where attendance falls below target for a
Ward/Dept/Team/Directorate/Division resulting in performance monitoring for the line
manager accountable, and where there are no mitigating circumstances.
3.0
Scope of the Policy
This policy applies to all staff, permanent, temporary, seconded, (including volunteers); in
all staff groups and all contract types, including bank workers, with the exception of:

5
Workers from Approved Agencies, including Locum Doctors. Such workers are
not required to attend a Corporate Induction, they will be provided with a Rapid
Induction pack when signing on for duty in Medical HR. In the case of emergency short
term locums arriving in the evening/night/weekend, they will report to the duty manager
on arrival and will be issued with an Rapid Induction Pack.
Royal Liverpool and Broadgreen University NHS Hospital Trusts

Temporary staff with contracts of less than 3 months. Such staff are not required
to attend Induction, they may be required to attend other mandatory training according
to their job role if not up-to-date with the required training. They will be provided with a
Local Induction Pack for temporary staff that includes a map of the appropriate site,
and a security badge by the local service manager.
Contracted staff. Induction and Mandatory training is the responsibility of the
employing organisation.

All staff that change roles within the Trust must undergo a Local Induction, and may attend
the Corporate Trust Induction if necessary. This is a central tenet of health and safety
legislation whether it is Induction or upon promotion with increased responsibilities for
health & safety.1
4.0
4.1


Policy
Definitions
Corporate Trust Induction - Taught generic programme suitable for all employees.
Local Induction Workbook - Generic workbook suitable for all employees (may
include Directorate/Dept information), which must be completed within the first month.
Local Induction Checklist - Generic checklist for all locum/agency staff who are on
RLBUHT premises for less than 3 months, which must be completed before
commencement of duties.
Rapid Induction Pack – Induction pack for short tem medical locums (normally from
an agency)
Permanent staff - All staff (permanent and temporary, including bank workers) under a
contract of employment with the organisation and medical staff in training, for more
than 3 months.
Temporary staff - Workers supplied by one organisation (e.g. locum/ agency workers)
for temporary use by another organisation. Temporary staff are the employees of the
supplying organisation Training Needs Analysis (TNA) and therefore the responsibility
for training, performance etc lies with the employing organisation not the Trust.
Minimum Data Set (MDS) - 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 these areas of risk management training
within the training needs analysis.
Training Needs Analysis (TNA) - A breakdown presented as a spreadsheet/table,
showing all staff groups, all training required by each staff group, and the frequency of
that training.
Mandatory Training refers to training, which has been approved as essential by the
Trust, after taking into account current legislation and guidance.
Core Skills Update is a one day Mandatory Training refresher. Staff may attend for all
or part of the day according to the TNA.
NHS North West Core Skills Framework is a proposed agreement between
organisations to accept mandatory training which has been undertaken elsewhere
provided that the organisation has signed up to delivering that training to an agreed
standard by appropriately qualified trainers.









4.2 Corporate Trust Induction
As a minimum, all new employees employed for over three months, must attend the 1 ½
day Corporate Trust Induction programme during their first week, with the exception of
1
The Management of Health & Safety at Work Regulations 1999 as amended
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
doctors in training (see below). The first 1 ½ days covers all of the mandatory legal, health
and safety training employees need during their first 2 years of employment (Appendix 1),
Additional mandatory training (Core Skills) is not therefore, required until their two year
anniversary. Corporate Trust Induction is followed by a “pathway” (see Table 1 below)
according to the individual’s job role.
Table 1
Monday
PATHWAY 1
Managers/Admin
Non Direct Care Staff
TRUST INDUCTION
PATHWAY 2
Direct Care Support Staff
PATHWAY 3
Direct Care Professionals
Medical Staff
TRUST INDUCTION
TRUST INDUCTION
Tuesday
TRUST INDUCTION
Local Induction
Wednesday
Local Induction
Thursday
Friday
Local Induction
Local Induction
TRUST INDUCTION
Introduction to Personal
Care
Manual Handling
Resuscitation
Local Induction
Local Induction
TRUST INDUCTION
Clinical Skills Refresher
Manual Handling
Resuscitation
Local Induction
Local Induction
Pathway 2 must be completed by all Direct Care Support Staff and Pathway 3 must be
completed by all Direct Care Professionals including Medical Staff.
The three pathways run on consecutive days and should be completed within the
employees first week of employment.
On completion of the Corporate Induction Pathways, all staff proceed to complete local
induction checklists (Appendix 2) for Permanent Staff or Staff employed for more than 3
months or (Appendix 3) for Temporary Staff employed for < 3 months or (Appendix 4 for
Locum and Agency Staff Medical Staff.
The exception to the above exists for Doctors in Training (F1/2 and ST Grades 1 – 5).
Corporate Induction for these staff group is provided as per Table 2
Table 2
Monday
Tuesday
Wednesday
Thursday
PATHWAY 4
F1 and Headroom F2
Corporate Induction as per
Programme (Appendix 5)
Friday
Monday
Tuesday
Wednesday
PATHWAY 5
ST 1 – 5 plus overspill of Headroom F2
Delivered August, December and April
(yearly)
Corporate Induction as per Programme
(Appendix 6)
Commence Local Induction
Commence Local
Induction
Continue onto Protected
Teaching Time Programme
see Appendix 7
Pathway 4 - All F1 Doctors are pre-employed 7 days before their post commences in
order for them to complete their Corporate Induction Programme. All Headroom F2
doctors (doctors who have not completed their F1 Training post within the Trust will be
encouraged to attend the F1 programme with Pay.
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
Pathway 5 - All ST1 – 5 doctors will attend a 2 day Corporate Induction Programme.
Headroom F2 doctors who have been unable to attend Pathway 4, should attend Pathway
5.
The Trust has agreed for Corporate Induction (F1 Programme and ST 1 – 5 Programme to
be undertaken at a local level for Emergency Department, Anaesthetics and Theatres and
the Dental Hospital. This agreement is made providing that the core elements listed below
are covered:
 Infection Control including Hand Hygiene and Inoculation Incidents
 Consent
 Medicines Management
 Transfusion
 Resuscitation
 Venous Thromboembolism
 Health and Safety, including Conflict, Slips, Trips and Falls & Manual Handling
 Information Governance including Record Keeping
 Harassment and Bullying
It shall be the role of these departments to ensure that all doctors in training in the
specialist areas complete induction training to the standard identified and provide records
of attendance to the Education Services for record keeping, monitoring and follow up of
non compliance. Local Induction Checklists must be completed as per this policy.
Additional Training for Doctors in Training (Pre and Post Induction)
All new doctors in training (F1/F2, ST1 – 5) starters are asked to complete a suite of E
learning modules which is considered to be integral to their Induction. This is part of a
Deanery accredited induction passport system and covers:
 Duties, Risk and Pressure
 Fire
 Hazardous Substances
 Infection Control
 Manual Handling
 Patient ID
 Safeguarding Adults
 Safeguarding Children
 Slips, Trips and Falls
 The Principles of Good documentation
Completion is automatically recorded on a learning management system which is shared
across the participating Trusts.
Education Services audit completion on the system. Doctors in training who fail to
complete within 2 weeks are reminded by email. Failure to complete within a further week
results in a further email copied to the Director of Post Graduate Medical Education for
action.
F1 Induction continues through the first 6 weeks of employment during protected teaching
session on Monday, Tuesday & Thursday lunchtime. See Appendix 7. Attendance
registers are held by Education Services,
Corporate Trust Induction Procedures
8
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Corporate Trust Induction is provided on set start dates which are known to managers a
year in advance to assist with recruitment. All new staff are automatically allocated dates
to attend the Corporate Induction Programme and appropriate pathway by the recruitment
team (Pathways 1 – 3) or Education Centre (Pathways 4 & 5) and are informed of those
dates by letter. Copies of letters are sent to managers, by Human Resources for
Pathways 1 - 3, for their information. Notification for Pathways 4 & 5, are through the
Education Centre direct to the Dr in training. Induction is measured by completion of
pathways 1 - 5 as described above.
A flowchart of the process for Induction Pathways 1 - 3 is shown below.
HR Responsibilities
Learning & Development HR Responsibilities
Responsibilities
Managers recruit to set start dates
& Permanent staff/ Temporary Staff
employed for >3 months appointed
and allocated a Corporate Induction
date
Recruitment send
dates for Induction
and pathway(s) to
new staff in the
recruitment pack
(cc to local manager)
New staff member attends the
Corporate Trust Induction and
appropriate Pathway(s)
Attendance records are
signed at the Corporate
Trust Induction.
Non-Attendance followed
up on day 1 with
Recruitment team
Recruitment send
new starter list to
Learning &
Development (L&D)
Services prior to
Induction
Attendance for the
Corporate Trust Induction
is entered onto the
training database (OLM)
by L&D Services
Recruitment send
Managers L& D new
starter monthly
reports (Last Friday
in the Month).
Monthly Workforce reports
produced by L&D on
attendance at Induction
against recruitment
Report to the Mandatory
Training Group, NHSLA Working
Group and Directorate
Mandatory Training Group and
Directorate Managers to address any
local issues arising from the reports
9
All non-attendees
automatically
booked onto the
next Corporate
Trust Induction by
recruitment team
(cc to local
manager)
Anyone failing to
attend Trust
Induction on a
second occasion
(without valid
reason) will be
reported to the
Directorate
Managers by HR
Recruitment
Services and will be
included in a non
attendance report
for further action
NHSLA Working Group to
address any organisational
issues arising from the reports
Royal Liverpool and Broadgreen University NHS Hospital Trusts
A flowchart of the process for Induction Pathways 4 & 5 is shown below:
Education Centre
Doctors in Training are recruited at
set start dates
and attend a Dedicated Corporate
Induction
New staff member attends
Pathway 4 –
All F1s are employed
7 days pre contract
in order to complete
Induction
Attendance records are
signed at the Induction
Programme.
Pathway 4 –
F2 Headroom Doctors
requested to attend F1
Induction Programme
Pathway 5 –
All ST 1 - 5 complete
2 day Induction
Programme during
the first week of
employment.
F2 Headroom Drs
who have not
completed Pathway 4
must completed
Pathway 5
Non-Attendance
followed up on day 1 by
Education Centre staff
Attendance lists for Induction
are sent to L&D to be entered
onto the training database
(OLM) by Education Centre
Monthly Workforce reports
produced by L&D on
attendance at Induction
against recruitment
Report to the Mandatory
Training Group, NHSLA Working
Group and Directorate
Mandatory Training Group and
Directorate Managers to address any
local issues arising from the reports
10
All non-attendees
booked onto next
Medical Staff
Induction
Programme or Core
Skills by Education
Centre who will
inform L&D
(cc to Clinical
Director and the
Director of Medical
Education)
Anyone failing to
attend Trust
Induction on a
second occasion
(without valid
reason*) will be
reported to the
Medical Director
and will be included
in a non attendance
report for further
action
NHSLA Working Group to
address any organisational
issues arising from the reports
Royal Liverpool and Broadgreen University NHS Hospital Trusts
4.3 Local Induction
A generic Local Induction Workbook (Appendix 2) is provided to the new employee by
the Learning and Development Department, on day one of the Corporate Trust Induction,
which covers general information suitable for all new employees. Directorates/Corporate
Services may add to the Local Induction Workbook to reflect specific Directorate needs, or
to address particular job requirements.
For individuals working on RLBUHT premises for less than 3 months, a condensed Local
Induction Checklist (Appendix 3) is available and must be carried out by the local
manager prior to the commencement of duty. The checklist covers the minimum
requirements suitable for all new members of staff to ensure patient safely is maintained.
It is expected that all agency workers/locum doctors familiarise themselves with local
procedures with local manager support as soon as reasonably practical and complete
Locum/Agency Rapid Induction Pack (Appendix 4).
Local Induction Procedures (Permanent/Temporary contract staff recently
employed)
A generic Local Induction Workbook (Appendix 2) is provided by the Trust, which covers
general information suitable for all new employees. Directorates/Corporate Services may
add to the Local Induction Workbook to reflect specific Directorate needs, or to address
particular job requirements.
As a minimum, all new permanent and temporary staff employed for > 3 months must
complete the Local Induction Workbook within the first month of their employment.
Managers must send the completed copy to Learning and Development Department for
recording completion on the Staff Training Record. Learning and Development will
forward the original to HR Services for filing on the personal file. Staff should retain a
copy. Compliance and non-compliance will be reported by the Learning and Development
Team monthly to the, Mandatory Training Group and NHSLA Working Group.
Local Induction for Temporary Staff i.e. approved Locum/Agency Workers
As a minimum, individuals working on RLBUHT premises for less than 3 months, a
condensed Local Induction Checklist (Appendix 3) must be carried out by the local
manager prior to the commencement of duty. The checklist covers the minimum
requirements suitable for all new members of staff to ensure patient safely is maintained.
Agency workers/locum doctors are expected to complete the Locum/Agency Rapid
Induction Pack (Appendix 4) with the Duty Manager or Local Requesting Manager and to
familiarise themselves with local procedures with local manager support as soon as
reasonably practical.
Duty Manager/Local managers must send the completed Rapid Induction Checklist to
Medical HR Services/Nurse Bank as applicable, who will retain a record, and a copy given
to the worker. Compliance and non-compliance will be recorded by the Medical HR
Services/Hospital Bank and reported to Learning and Development Department for
inclusion in the monthly reporting on compliance/non compliance to Mandatory Training
Group and NHSLA Working Group, by Learning and Development Services.
11
Royal Liverpool and Broadgreen University NHS Hospital Trusts
When an existing member of staff transfers to a new post within the Trust, the Trust
considers it good practice for the member of staff to work through the Local Induction
Workbook, to assist them to settle in to their new role. The Local Induction checklist
should be sent to the Learning and Development Department who will forward a copy to
HR Services for the personal file, and staff should retain a copy. Development needs may
be addressed during appraisal.
A flowchart of the process for Local Induction is shown below.
Permanent/Temporary Staff Employed
For > 3 months
Locum/Agency and
Temporary Staff employed
For < 3 months
Request for Temp noted to
Hospital Bank/Medical HR
New Staff
member
appointed
Existing Staff member
transfers between jobs –
Considered Good
Practice
Receives Local Induction
Workbook at Corporate
Induction
Local Induction Workbook
completed with line
manager/mentor
(During first month)
Manager/staff sign to confirm
completion of Local Induction
Manager sends copy to
Learning and Development for
recording on the training
database (OLM)
Copy given to staff
Leaning and Development
send copy to Medical HR or
Liverpool HR Services to
maintain record of
completion on the personal
file
(From agency, Locum Doctors etc.
less than 3 months)
Temp worker appointed
(From agency, Locum Doctors etc.
less than 3 months)
Given Local Induction Checklist
or Rapid Induction Pack by
requesting manager or duty
manager (out of hours) to
complete at commencement of
shift
Monthly Workforce
Information report
produced by L&D
monitored by
Mandatory Training
Group informed and
NHSLA Working
Group.
HR Director informed
and action taken on
anyone failing to
complete Local
Induction (without
valid reason*)
Manager and temp worker
sign form to confirm local
induction has been completed
before commencement of
duties
Form copied - one sent by
service manager to Medical
HR/ Hospital Bank, as
applicable for filing/recording
and one retained by the
worker.
Report sent to the L&D Dept
that local induction has been
completed. L&D to report to
Director of HR non compliance
of Agency and Locum staff to
action with Directorates
*Valid reasons for non completion of Local Induction include but are not exclusively, sickness/absence, special leave, and/or other
exceptional circumstances.
Follow up of Non Attendance and Local Induction Checklists
12
Royal Liverpool and Broadgreen University NHS Hospital Trusts
The Learning and Development Department will follow up, with HR, all staff who have not
attended the Corporate Induction Programme to ascertain if the person accepted the offer
of employment or not. If employment was accepted HR will allocate a further date and
inform the member of staff of their need to attend. A second failure will be escalated to the
Directorate Manager and Director of HR for appropriate disciplinary action.
The Education Centre will follow up any Doctors in training who fail to complete Corporate
and Local Induction. Clinical Directors will be notified of failings.
Arrangements will be made for the doctor to receive training by the Director of Medical
Education. A second failure will be escalated to the Medical Director for appropriate
disciplinary action.
The Learning and Development Department will follow up all staff who have attended the
Corporate Induction Programme to ensure that their local induction process has been
completed. This will be undertaken monthly and reported as described above. Local
Managers will be informed of any failings to comply and requested to ensure local
induction is completed. Were non compliance continues this will be reported to the
Divisional Management Team and Director of Human Resources for immediate action.
Monitoring of compliance will be through the monthly reporting process described above,
with the Mandatory Training Group and NHSLA Working Group.
For all Locum/Agency, Medical HR/Duty Manager and the Hospital Bank will be
responsible for ensuring that local induction is performed and the checklist completed on
the first day of employment.
4.4. Mandatory Training
Mandatory training is essentially risk management training designed to maintain the safety
of both patients and staff. The Trust will comply with the NHS Northwest Core Skills
Framework to ensure consistency between local organisations and to reduce duplication of
training when staff transfer between organisations. This is currently in the pilot stages.
Some mandatory training will be the same for all groups of staff, other types of mandatory
training are only required by certain groups of staff, and some will be tailored according to
need and specific job roles. Mandatory Training requirements according to staff groups
and frequency of updates are set out in the Mandatory Training Matrix (Appendix 8).
12 essentials have been defined as mandatory at RLBUHT; These are delivered as
part of Corporate Induction, Core Skills Update and Clinical Skills Refresher programmes.
1. Corporate Trust Induction
2. Local Induction
3. Fire Safety
4. Moving & Handling (Patient Handling & Object Handling)
5. Conflict Resolution (includes Lone Worker and Harassment & Bullying)
6. Equality, Diversity & Human Rights
7. Resuscitation training
8. Health, Safety & Security (including slips, trips and falls)
9. Infection Prevention & Control (including Hand Hygiene, inoculation incidents)
10. Safeguarding Children
11. Safeguarding Vulnerable Adults
12. Information Governance & Health Record Keeping
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
Mandatory Training will be centrally provided over a maximum of one day to support staff
release and minimise workplace disruption. The one day “Core Skills Update” (Appendix
9) will be structured so that staff groups attend for all or part of the day according to need.
An additional “Core Clinical Skills Update” is available to meet local needs in line with
the minimum data set for clinical staff. It is expected that clinical staff will receive this
update every two years.
Mandatory Training may also be delivered locally to suit needs, as either taught sessions
or work based learning, and where appropriate, e learning will be available as an
alternative access to learning.
The Trust will comply with the basic requirements within the Training Needs Analysis
(TNA) of the NHSLA Minimum Data Set (MDS). The requirements will be met through
both the corporate and local induction and mandatory training identified within this policy
and the TNA.
Clinical/Professional/Role Specific Mandatory Training may also be agreed within
Directorates/Corporate Services according to local need. This policy does not cover
mandatory training requirements for continuous professional development purposes for
specific staff groups or individuals.
Continuous Professional Development (CPD)
mandatory training will be identified and agreed within Directorates for groups of staff, e.g.
safety roles in Estates and Facilities, and may be included in Divisional Business Plans.
Learning and Development Services will support compliance with Divisional Business
Plans, by maintaining central training records of compliance.
4.4.1 Required attendance at Mandatory Training:
RLBUHT expects everyone to attend all the mandatory training required of them in their
role. A minimum of 80% attendance/compliance is expected. This minimum target will be
reviewed according to organisational needs/risk assessment.
Staff are expected to attend on their allocated date(s)/complete the required learning,
unless there are exceptional circumstances, and the line manager agrees to cancel the
place. Cancellations will only be accepted from a line manager, not a member of staff and
line managers are expected to give reasons for non attendance, which will be recorded by
Learning and Development, to assist with reporting. Arrangements must be made by the
individual member of staff to attend/complete the required learning on an alternative date.
Staff may be unable to attend any other training/study leave unless they have
attended/booked place for all the mandatory training required of them for that year.
Failure to attend/complete the required learning (without valid reason) by the individual
may result in disciplinary action/withholding of pay progression as safe practice is
compromised. Likewise, managers must plan and monitor staff release, they must ensure
that staff attend training/complete the learning required of them, and they must take action
to follow up non attendance and/or shortfall against agreed target, otherwise they too may
be subject to disciplinary action/withholding of pay progression as the safety of the work
environment is compromised.
Mandatory Training
The Mandatory Training Matrix (appendix 8) details all the required training and frequency
of updates by staff group. How that training is provided will vary according to the topic and
14
Royal Liverpool and Broadgreen University NHS Hospital Trusts
will be available as e learning/work based learning where appropriate and relevant.
RLBUHT is complying with the framework for mandatory training set out in the NHS
Northwest Core Skills Passport.
Most staff require an update every 2 years in some generic core skills. To support this, a
½ day “Core Skills Update” is provided with dates and times a year in advance to support
managers plan for staff release. Managers and staff agree a timetable for attending
mandatory training, and staff will be booked on training as far in advance as possible,
ensuring that rotas etc. reflect attendance. Managers will also monitor attendance taking
action on non attendance or where there is a shortfall.
Some Mandatory Training may be provided locally within Directorates, or as work based
learning and it is imperative that signed attendance records are submitted to Learning and
Development Services within one week of the programme to ensure accurate recording
and reporting. Completed E learning is able to be audited centrally for reporting.
A flowchart of the process for Mandatory training is shown below.
Mandatory Training Matrix
agreed showing
requirements by staff group
“Core Skills Updates”
arranged in sufficient
capacity to meet needs and
dates are published
Local/Work based learning
is arranged to meet
mandatory training needs
E learning is available to
meet mandatory training
needs
Manager books staff onto
dates as far as possible in
advance
Manager/local trainer
ensures that attendance
registers are signed and
submitted to L&D services
(within one week)
Manager ensure staff has
access to appropriate e
learning
Staff attend and sign
register
Attendance on Mandatory
Training (Core Skills) is
entered onto the training
database (OLM) by L&D
services
Monthly Workforce Information report produced by
L&D monitored by Mandatory Training Group and
Directorates.
Directorates take action on anyone failing to
complete Mandatory Training (without valid reason)
Report to the NHSLA Working
Group and Divisions for further
action.
4.5
Follow Up Arrangements for all Training identifies in the TNA
Different processes exist for each type of training and how non attendance is followed up.
15
Royal Liverpool and Broadgreen University NHS Hospital Trusts
4.5.1 Follow up of Core Skills/Clinical Core Skills ; Manual Handling Practical/
Resuscitation Practical and Conflict Resolution
Refresher – Reminders
Learning and Development will notify staff members of their need to complete refresher
(update) training by email 16 weeks before expiry of their previous training date, with a
copy sent to their manager. The staff member is expected to book onto a suitable training
date before their expiry date.
Learning and Development will monitor compliance and follow up staff members who have
not rebooked 8 weeks before their expiry date with a further email.
Learning and Development will send a final reminder to the staff member and manager 1
week before their expiry date. A further non compliance will be escalated to the Divisional
General Manager for further action.
Follow up staff who “Did Not Attend” - DNAs
Learning and Development Team produce weekly reports for Directorate Managers and
Heads of Departments that identify non attendance. The Directorate Manager/Head of
Department is requested to rebook the individuals onto training immediately but no later
than 2 weeks.
In addition monthly reports are produced by Learning and Development and sent to
Directorate Managers and Heads of Department of staff who are non-compliant with their
training needs. Directorate Managers and Heads of Department are requested to address
these training gaps.
Learning and Development Team audit re-bookings and inform the Divisions of any
ongoing concerns, for action.
4.5.2 Follow up of Consent - General Principles
This forms part of Induction training and is followed up as described in section 4.3 of this
policy.
There is no follow up arrangements in place for procedure specific training as this is part of
healthcare professional development and there are no time limits in place. However, non
compliance is monitored through the Consent Audit and deficiencies acted upon (refer to
Consent to Treatment and Examination Policy.
4.5.3 Follow up of Investigation of Incidents, Complaints and Claims
The Risk Management Team, rebook those who fail to attend training and monitor
compliance through an annual audit. Staff who fail to complete this training are targeted
until complete. Escalation is through the Divisional Management Team.
4.5.4 Follow up of Medical Device Training
Please refer to the Medical Devices Policy.
4.6
16
Process for Developing the Training Needs Analysis (Appendix 8)
Royal Liverpool and Broadgreen University NHS Hospital Trusts
The Trust has set up an Education Governance Group who has the responsibility of
overseeing the Trust Learning Investment Plan (Training Plan), prioritising all training
needs and authorising any new learning. The Education Governance Group reports into
the Finance and Performance Committee which is a sub group of the Trust Board.
The Trust has also recently introduced a revised annual Business Planning process which
includes a workforce and training plan. In the future, the training needs will be collated
from this process, and presented as an annual Learning Investment Plan in April of each
year to the to the Education Governance Group. Prioritised needs will be offered in the
Trust’s Annual Training Prospectus, which will be kept under review to respond to
emerging needs throughout the year. As an interim, the Head of Learning and
Development has interviewed every Directorate Manager and specialist subject lead to
establish broad training needs arising from service plans and appraisal discussions. This
information has been developed into a training needs analysis and draft Learning
Investment Plan for approval by the Education Governance Group.
The design and delivery of Multi Professional learning is monitored and agreed through the
Multi Professional Training Group who report into the Education Governance Group.
The delivery of Mandatory Training is kept under review by the Mandatory Training Group
who report into the Education Governance Group. A key responsibility of the Mandatory
Training Group, as outlined in the terms of reference, is keep under review the Training
Needs Analysis of all staff. Key members of the Mandatory Training Group include all lead
trainers who deliver on induction and mandatory training for all staff groups. The group is
charged with pro-actively assessment the current TNA to ensure:
 the identification of all staff’s corporate induction and mandatory training
requirements reflect current legislation and statute, and includes the core minimum
requirements referred to in the NHSLA standards, and is included as the minimum
core content in the Trust’s Corporate Induction, and appropriate Mandatory training.
 the training requirements detailed within specific trust policies are incorporated
 there is consultation with Trust staff that have specific responsibilities for leading on
risk related agendas.
The Training Needs Analysis set in policy then details what the Trust deems as mandatory
training, that is appropriate to targeted staff groups, including the frequency of training or
update training, together with appropriate time periods.
The purpose of identifying time periods is to ensure that training resources are targeted to
the most appropriate staff groups at the most appropriate intervals, recognising that
different staff groups will require different levels of skills, knowledge and understanding in
order to fulfil their roles.
Additions may be made to TNA in year on the basis of reacting to new requirements or Trust
concerns. These will be discussed at the Mandatory Training Group and the TNA updated.
The TNA is published on the Learning and Development Website.
Creating and Action Plan for the Delivery of identified training
Once the TNA has been ratified at the Mandatory Training Group, and the Education
Governance Group, an action plan will be agreed to meet the key learning needs within
the available budget.
17
Royal Liverpool and Broadgreen University NHS Hospital Trusts
A programme to meet mandatory learning needs is agreed and this includes specific
delivery programmes, delivery dates and lead responsibility for specified programmes.
This is added to the Mandatory Training Groups action plan.
4.
Process for Developing an Annual Training Prospectus
The Trust will provide an annual Training Prospectus for Managers to help target specific
training for staff groups. The Training Prospectus will detail training requirements and
frequency of training provided by Learning and Development Department.
The Training Prospectus will be readily available on the Trusts Intranet Site.
An annual report of implementation of the Training Needs Analysis will be produced by the
Learning and Development Department at the end of each financial year and disseminated
through the Trust intranet.
4.8 All training in respect of this policy delivered by the Trust will be recorded onto the
Trust training database (OLM) with the exception of medical devices.
5.0
Roles & Responsibilities
5.1
Responsibility of Mandatory Training Group /Trainers
 The Mandatory Training Group is responsible for monitoring that all new employees,
attend Corporate Trust Induction, receive work based Local Induction, and attend their
required mandatory training.
 Review the Corporate Trust Induction, the Local Induction Workbook/Checklists, and all
mandatory training to ensure it is fit for purpose, compliant with legislation/guidelines,
and consistent with the standard agreed under this policy.
 Review the Mandatory Training Report in detail, ensuring that action is communicated
to managers and/or changes made to maintain compliance with this policy.
 Monitor efficacy of training in the light of litigation, increase in accident/incident ratios.
 Deliver key messages during training in line with best practice in a professional manner
which encourages staff to learn and put their learning into practice
 Make themselves available to deliver all sessions, finding a competent person to
substitute them well in advance if they are unable to attend
5.2
Responsibility of Director of HR & Organisational Development
 The Director of HR & OD has overall accountability for this policy.
5.3
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5.4
18
Responsibility of Deputy Director of HR & Organisational Development
Oversee the introduction, monitoring and implementation of this policy to ensure a fair
and consistent application throughout, answering queries in relation to this policy.
Ensure provision of guidance and support to Managers on the operation of this policy.
Lead the review of the content of Induction & Mandatory training in consultation with
the Mandatory Training Group, ensuring that the Education Governance Committee
approves significant changes.
Ensure Induction and Mandatory training is recorded and reported against agreed
targets, ensuring regular reports are sent to Directorates/Corporate Service Managers.
HR Business Partners will
Royal Liverpool and Broadgreen University NHS Hospital Trusts

Participate in the Directorate/Corporate performance reviews to discuss progress
against agreed targets, and support managers to find ways of ensuring staff attend
required mandatory training.
5.5
The Risk Manager will
 Advise on the content of training in accordance with the requirements of statute, NHS
guidance including NHSLA. The Risk Manager will act as a link between the Risk
Management and Mandatory Training Group.
5.6

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




Recruitment Services will
Monitor recruitment practices to set start dates, raising concerns where managers are
recruiting outside agreed set start dates without approval.
Correspond with new employees detailing the requirement to attend Corporate Trust
Induction, undertake Local Induction, and complete all mandatory training.
Allocate new employees to the Corporate Trust Induction and mandatory training
identified in the Induction pathway for their role, confirming those dates with the line
manager and with Learning & Development Services.
Advise new employees on the date(s) on which they will be expected to attend
Corporate Trust Induction, including sending out Induction information in advance.
Provide information on numbers of new starters against those recruited, and those
commencing employment prior to attending Corporate Trust Induction for inclusion in
the Induction and Mandatory training report.
Receive completed Local Induction from Learning and Development/Education Centre
and record and retain in personal files.
Follow up temporary staff local induction checklists.
5.7 Education Services & Learning & Development Team will




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


Organise Corporate Trust Induction and Mandatory Training in sufficient capacity to
meet needs.
Inform managers of Corporate Trust Induction and Mandatory training dates in advance
to support recruitment and study leave decisions.
Provide advice and support for managers on the flexibility of training, and in the
provision of locally delivered training.
Provide admin support/host service for all Induction and Mandatory training events to
monitor that attendance registers have been signed, to provide support for presenters,
and to ensure smooth running of events for those attending.
Inform recruitment services/managers when staff have failed to attend Induction for
local managerial action.
Maintain central attendance records, evaluations and content of training programmes,
including signed records of attendance, and evidence of completed local induction.
Forward Local Induction Checklists to Recruitment Services for filing.
Produce standard, regular training attendance and non-attendance reports for
internal/external audit, including ad hoc reports where required, ensuring that all data is
analysed and presented in the required format and timescales for meetings/briefings.
5.8 Education Service Team will:
 Ensure Induction is in place as required for all medical staff in training, Consultant
Medical staff will attend the Trust Corporate Induction programme and complete the
Local Induction Workbook.
5.9 Directorate Managers will;
19
Royal Liverpool and Broadgreen University NHS Hospital Trusts

Ensure all staff in their operational control attend Corporate Trust Induction, complete
Local Induction Workbooks/Checklists, and are released to attend mandatory training.

In exceptional circumstances, the Directorate Manager may sanction a new starter to
commence prior to Corporate Trust Induction. In these circumstances, Local Induction
must take place, and the staff member must attend the next available Corporate
Induction.
Be responsible for cascading this policy throughout their services, ensuring that
arrangements are in place to comply with this policy, particularly dissemination and
communication, and any updates to all staff.
Discuss progress against targets at the local Directorate/Corporate performance review
meetings, ensuring that follow up managerial action takes place resulting from nonattendance, shortfall against target, or failure to complete documentation correctly.
Agree additional professional/role specific mandatory training and include in the
Directorate/Corporate Business Plan.
Monitor local compliance with this policy, alerting Learning and Development Services
to any difficulties, and make suggestions for improvements.




5.10

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









Ensure that all staff are recruited on the agreed set start dates, and that duty rotas/shift
pattern/hours of work reflect attendance on the full Induction programme.
Welcome new members of staff to the Ward/Department, including both new
employees to the Trust, and staff who are transferring from another ward or dept.
Assign workplace mentor to new employees to explain the work of the department, how
it fits into the Trust, ensuring that Local Induction Workbooks/Checklists are available.
Ensure that the Trusts standard Local Induction Workbook is used only adding to it
when other ward/dept specific information is deemed essential for new starters.
Ensure that Local Induction Workbooks/Checklists are completed and signed, that both
the individual has a copy, and that a copy is sent to Learning and Development or
Education Centre for recording and forwarding to Recruitment Services for filing in the
personal file.
Ensure that all staff are allocated dates for appropriate mandatory training and that
nominations are forwarded to Learning and Development Services.
Ensure that staff attend (or are booked to attend) their required mandatory training
before agreement is reached to attend any other training.
Ensure that all staff are given the time to attend their required mandatory training, as
part of the working week, paid time, or as time paid back in lieu.
Sanction non attendance when absolutely necessary, personally contacting Learning
and Development Services giving the reason for non attendance (cancellations will not
be accepted from the member of staff)
Review attendance and non-attendance mandatory training reports following up
reasons for non-attendance, taking managerial action where required.
Ensure that, if local training takes place, it is to the standard outlined in this policy, and
that attendance registers are signed and submitted within one week to Learning and
Development Services for recording and reporting.
Review the job related mandatory training needs of all posts during appraisal to identify
any changes to requirements e.g. manual handling.
Inform own line manager of any circumstance preventing compliance with this policy.
5.11
20
Line Managers will
All Staff will
Royal Liverpool and Broadgreen University NHS Hospital Trusts

Complete the full Corporate Trust Induction programme and complete the Local
Induction Workbook/Checklist as directed, retaining a copy of their learning.

Attend mandatory training on the day allocated, arriving on time and remaining for the
full session. Arriving late/leaving early will not be recorded as an attendance.
If unable to attend due to exceptional circumstances, permission for non attendance
must be gained from the line manager; who must inform Learning and Development
Services. Apologies for non attendance will not be accepted from individuals.
Complete/have a booked place on the full mandatory training programme as required
for the role prior to requesting any additional study time.
Apply the knowledge and skills acquired on mandatory training at all times, alerting the
line manager if any aspect of practice contravenes the advice and guidance provided
on mandatory training.



6.
6.1
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







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
Associated Documentation and References
Legal Requirements, National Standards/Guidance
Health & Safety at Work Act 1974
Health and Social Care Act 2001
The Race Relations Act 1976 (as amended by the Race Relations (Amendment) Act
2000)
The Disability Discrimination Act 1995 amended 2005
The Gender Recognition Act 2004
The Civil Partnership Act 2004
Employment Equality (Religion or Belief) Regulations 2003
Employment Equality (Sexual Orientation) Regulations 2003
Sex Discrimination (Gender Reassignment) Regulations 1999
The Human Rights Act 1998
The Sex Discrimination Act (as amended) 1975
The Equal Pay Act (as amended) 1970
Promoting Equality and Human Rights in the NHS – A Guide for Non-Executive
Directors of NHS Boards (2005) Department of Health
NHSLA
Essential Standards of Quality and Safety
Code of practice for prevention and control of health care associated infection
Fire Safety Policy & the Firecode
Regulatory Reform (fire safety) Order 2005
Resuscitation Guidelines
Safeguarding Children
No Secrets – Safeguarding Vulnerable Adults
A Professional Approach to Managing Security in the NHS 2003
Learning & Development Programme (Organisation Wide Prospectus)
Policy For The Development And Management Of Policy And Procedural Documents
6.2
Documentation
The following documentation is provided for Corporate Trust Induction, Local Induction &
Mandatory Training.
Directorates and Corporate departments must use this
documentation and only supplement it with Directorate specific information vital to the role
of the individual. The Mandatory Training Group is responsible for reviewing all
documentation and issuing updated versions.
 Corporate Induction Programmes (Appendix 1/5/6)
 Local Induction Workbook Permanent Staff(Appendix 2)
 Local Induction Checklist Temporary Staff (Appendix 3)
21
Royal Liverpool and Broadgreen University NHS Hospital Trusts
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

Rapid Induction Pack (Locum/Agency Doctors (Appendix 4)
Core Skills Update Programme (Appendix 9)
Mandatory Training Matrix (TNA) (Appendix 8)
7.
Training
Briefing and dissemination of this policy will be via Corporate Management Team, the Risk
Management Sub Committee; Team Brief cascaded through Directorate meetings. The
latest policy is held on the Intranet.
Directorate Managers are responsible for
disseminating this policy throughout their Directorate and ensuring that line managers and
staff are aware of their responsibilities under this policy. The Deputy Director of
Organisational Development will support Directorate Managers with advice and guidance.
8.
Monitoring & Audit
The Table below demonstrates how the Trust will monitor compliance for Induction and
Mandatory training for all permanent and Temporary Staff:
Minimum
requirement to be
monitored
Process for
monitoring e.g.
audit
Responsible
individual/ group/
committee
Frequency of
monitoring
Responsible
individual/
group/
committee for
review of
results
Responsible
individual/
group/
committee for
development
of action plan
Responsible
individual/group/
committee for
monitoring of
action plan and
Implementation
Duties
Implementation
of audit
programmes
detailed below
minimum content
of corporate / local
induction
programmes
Audit of
implementation
of Induction and
Mandatory
Training
arrangements
as per TNA
Learning and
Development
Department
Quarterly
NHSLA Working
Group
Learning and
Development
Department
NHSLA Working
Group
process for
ensuring that all
new permanent
staff are booked
onto corporate
induction
Audit of
implementation
of Induction and
Mandatory
Training
arrangements
as per TNA
Learning and
Development
Department
Quarterly
Learning and
Development
Department
NHSLA Working
Group
process for
checking that all
new permanent
staff complete
corporate /local
induction
Audit of
implementation
of Induction
and Mandatory
Training
arrangements
as per TNA
Learning and
Development
Department
Quarterly
Learning and
Development
Department
NHSLA Working
Group
process for
checking that all
temporary staff
complete local
induction
process for
following up
permanent staff
who fail to attend
corporate/local
induction
process for
following up
temporary staff
who fail to
complete local
induction
22
Audit of
implementation
of Induction
and Mandatory
Training
arrangements
as per TNA
Mandatory
Training Group
Mandatory
Training Group
NHSLA
Working Group
Mandatory
Training Group
Medical HR
Services/Hospital
Bank
Quarterly
Learning and
Development
Department
Quarterly
Medical HR
Services/Hospital
Bank
NHSLA Working
Group
Quarterly
HR Services
NHSLA
Working Group
Learning and
Development
Department
NHSLA
Working Group
Education
Governance group
Education
Governance
group
NHSLA
Working Group
Mandatory
Training Group
Education
Governance group
NHSLA Working
Group
NHSLA Working
Group
Education
Governance
group
HR Services
NHSLA Working
Group
Royal Liverpool and Broadgreen University NHS Hospital Trusts
The Table below demonstrates how the Trust will monitor against the NHSLA Standards
on the process for ensuring a systematic approach to risk management training for all
permanent staff:
Minimum
requirement to be
monitored
Process for
monitoring e.g.
audit
Responsible
individual/
group/
committee
Frequency of
monitoring
Responsible
individual/
group/
committee for
review of
results
Responsible
individual/
group/
committee for
development
of action plan
Responsible
individual/group/
committee for
monitoring of
action plan and
Implementation
Process for
developing a TNA
which must include
all those topics
referred to in the
TNA Minimum
Data Set
Audit of
Mandatory
Training Group
and
development of
TNA
Learning and
Development
Department
Annual
NHSLA Working
Group
Learning and
Development
Department
NHSLA Working
Group
Process for
developing action
plans to deliver the
training identified
within the TNA
Audit of
Mandatory
Training Group
and
development of
TNA
Learning and
Development
Department
Annual
Learning and
Development
Department
NHSLA Working
Group
Process for
developing an
annual training
prospectus which
reflects the TNA
Audit of
Mandatory
Training Group
and
development of
TNA
Learning and
Development
Department
Annual
Learning and
Development
Department
NHSLA Working
Group
process for
checking that all
permanent staff
complete the
relevant training
programmes in
accordance with
the TNA
Audit of
implementation
of Induction
and Mandatory
Training
arrangements
as per TNA
Learning and
Development
Department
Quarterly
Learning and
Development
Department
NHSLA Working
Group
process for
following up
those who fail to
attend relevant
training
programmes
Audit of
implementation
of Induction
and Mandatory
Training
arrangements
as per TNA
Learning and
Development
Department
Quarterly
Learning and
Development
Department
NHSLA Working
Group
Process for coordinating training
records
Audit of
implementation
of Induction and
Mandatory
Training
arrangements
as per TNA
Learning and
Development
Department
Quarterly
Learning and
Development
Department
NHSLA Working
Group
Mandatory
Training Group
NHSLA Working
Group
Mandatory
Training Group
NHSLA Working
Group
Mandatory
Training Group
NHSLA
Working Group
Mandatory
Training Group
NHSLA
Working Group
Mandatory
Training Group
NHSLA Working
Group
Mandatory
Training Group
Education
Governance group
Education
Governance group
Education
Governance group
Education
Governance group
Education
Governance group
Education
Governance group
The Table below demonstrates how the Trust will monitor against the NHSLA Standards
on how the organisation has documented its TNA to identify Risk Management Training for
all permanent staff:
Minimum
requirement to be
monitored
Process for
monitoring
e.g. audit
Responsible
individual/
group/
committee
Frequency of
monitoring
Responsible
individual/
group/
committee for
review of results
Responsible
individual/
group/
committee for
development
of action plan
Responsible
individual/group/
committee for
monitoring of
action plan and
Implementation
a list of topics
defined as risk
management
training by the
Audit of
Mandatory
Training
Group and
Learning and
Development
Department
Annual
NHSLA Working
Group
Learning and
Development
Department
NHSLA Working
Group
23
Mandatory
Education
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Organisation (must
include all those
referred to in the
TNA Minimum Data
Set
development
of TNA
Training Group
Evidence that the
organisation has
identified which staff
groups are required
to attend each type
of training
Audit of
Mandatory
Training
Group and
development
of TNA
Learning and
Development
Department
Annual
Evidence that the
organisation has
identified the
frequency of
updates required for
each type of training
Audit of
Mandatory
Training
Group and
development
of TNA
Learning and
Development
Department
Annual
NHSLA Working
Group
Mandatory
Training Group
NHSLA Working
Group
Mandatory
Training Group
Governance group
Learning and
Development
Department
NHSLA Working
Group
Learning and
Development
Department
NHSLA Working
Group
Education
Governance group
Education
Governance group
8.1
Recording and Monitoring of Equality & Diversity
The Trust understands the business case for equality and diversity and will make sure that
this is translated into practice. Accordingly, all policies and procedures will be monitored to
ensure their effectiveness.
Monitoring information will be collated, analysed and published on an annual basis as part
of our Single Equality and Human Rights scheme. The monitoring will cover all strands of
equality legislation and will meet statutory employment duties under race, gender and
disability. Where adverse impact is identified through the monitoring process the Trust will
investigate and take corrective action to mitigate and prevent any negative impact.
The information collected for monitoring and reporting purposes will be treated as
confidential and it will not be used for any other purpose.
8.2 Recording and Reporting
Learning and Development Services and HR Services will work together to provide
appropriate standardised workforce information reports in sufficient detail to meet the
varying needs of the Trust Board, Risk Management Group, Mandatory Training Group,
Divisions and Directorates. This includes processes to capture e learning (when in place)
Reporting will be a RAG rated attendance against target expressed as both a headcount
figure and percentage with supporting narrative. Reports are available by staff group, or
by mandatory training topic, and will be presented in different formats to meet different
needs ranging from an overall Trust summary to Directorate based detail. Ad hoc reports
and information will also be provided as required by the Trust for internal/external audits.
Standard reports are provided as follows,
 Weekly non attendance reports which include reasons for non attendance.
 Monthly Mandatory training attendance reports, which include collated reasons for non
attendance.
 Monthly Induction attendance against staff recruited.
 Monthly verification report of completion of Local Induction.
8.3 Reporting process
Managers have ultimate responsibility to ensure this policy is implemented by ensuring
that staff are receiving the correct Induction and Mandatory Training for their role, and by
taking action to address non attendance and shortfall against target. The Mandatory
Training Group have overall responsibility for receiving and acting upon reports and audits
24
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Type of report
(RAG rated against
trajectory)
DNA number &
name
DNA number &
name by Directorate
Attendance/DNA %
& number by topic &
by Directorate/Corp
Attendance/DNA %
& number by topic &
by Division/Corp
Corporate
Induction
Local
Induction
Mandatory
training
to improve compliance with this policy by working with managers to meet their
requirements. Compliance/non-compliance against this policy will be reported to the Risk
Management Committee by the Deputy Director of HR & OD. The Trust Board will receive
assurance on compliance from the Director of HR & OD.
Staff
group
P2
T3
X
Frequency
days
1
7
Frequency
months
1
3
6
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Evidence base
Reported to
Committee/Group
Non attendance on
day 1 of Induction
Weekly non
attendance report
Directorate and by
topic Workforce
Information Report
Divisional Workforce
Information Report
Recruitment Team
Directorate Managers
Corporate Heads
Mandatory Training
Group, Directorate
Managers/Corp Heads
RMSG & CMT, HR
Business Partners
Education Governance
Group
Trust Board
Summary
Summary Workforce
X
X
X
X
X
Attendance/DNA %
Information Report
DNA - Non-Attendance, L&D – Learning & Development, RMSG – Risk Management Strategy Group, CMT – Corporate Management
Team.
8.4
Document Control including Archiving Arrangements
Archived documents, which record updates of policy, are stored within the Governance
Department. All paper registers, attendance and non-attendance are stored for 3 years
within Learning & Development Services before shredding. Training reports are stored as
per IMT policy. Archiving takes place as documents are updated and/or on a two yearly
basis.
8.5
Register/Library of Procedural Documents
The register/library of procedural documents is kept with the Governance Department and
Trust intranet.
The Governance Department is responsible for maintaining the
register/library of procedural documents.
8.6 Process for Retrieving Archived Documents
Archived Induction and Mandatory Training documents can be retrieved by Learning &
Development Services with agreement from the Deputy Director of Organisational
Development.
9
Consultation
The Mandatory Training Group is the primary focus for consultation. Directorate Managers
have been given the opportunity to comment and a briefing was provided to the Corporate
Management team. The Trust recognises the need for all staff to be involved in
implementing and applying the policy. The key requirements of the policy will therefore, be
included on the Intranet and in communication bulletins.
10
Approval and Ratification
Clinical Governance & Risk Management Sub Committee
2
3
P – Permanent Staff
T – Temporary Staff – including Agency/Locum Doctors
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
Appendix 1
Appendix 1
Corporate Trust Induction
DAY 1 – Living our Local Values - Customer Care (ALL STAFF)
08.45
09.00
09.10
09.25
09.45
10.30
11.00
11.10
11.25
12.00
12.30
13.15
13.45
14.15
15.00
15.15
15.45
16.15
16.45
26
Registration
Welcome & Introduction
Getting to know you
IT Training Needs
Analysis and Briefing
Our Trust – Welcome!
An introduction to the Trust, the way the Trust is organised,
key priorities, mission, vision and values
Electronic Information & Governance
The importance of legislation and procedures affecting us all,
including data protection and health record keeping.
Introduction to today’s NHS – Customer Care
An interactive discussion on today’s health service and how
RLBUHT customer service values support patient care.
Spiritual Care
Refreshment break
Our Staff – Welcome!
An interactive discussion on what to expect as a member of
our staff. You will receive an overview of our policies to
support and guide you, including your health and well being.
Counter Fraud
An explanation of what constitutes fraud in the NHS and what
to do if you suspect anything untoward.
LUNCH & Representative stalls
Safeguarding Children and Vulnerable Adults
An overview of the policies and procedures, which apply to
everyone working in a health care setting.
Manual Handling Theory
Protect your back! An overview of the theory of Manual
Handling to prevent injury to yourself and/or the patient.
Fire Safety
A practical guide on what to do in the event of a suspected or
actual fire.
Refreshment break
Infection Prevention & Control/Hand Hygiene
An introduction to Infection Prevention and Control measures
that will help to keep both patients and staff safe, and
contribute to reducing infections.
Equality, Diversity and Human Rights
The importance of equality, diversity and human rights in
health care, and our responsibilities according to Trust policy.
Risk Management, Health Safety & Security
An introduction to the importance of the management of risk
Health, Safety and Security, and what our responsibilities are
in our everyday work. Practical advice will be provided on
what to do, and who to contact according to Trust policy.
Questions /Close Session
Sue Jones
IT Training team
Executive
Director
Information
Governance
EtL Facilitators
Chaplaincy
HR/OD Manager
Payroll &
Pensions
Counter Fraud
Specialist
Safeguarding
Lead
Manual Handling
Trainer
Fire Safety Officer
Infection Control
E&D Lead
Risk Management
Health, Safety &
Security
Managers
Royal Liverpool and Broadgreen University NHS Hospital Trusts
.
Corporate Trust Induction
DAY 1: Representative Stalls (12.30)
 LIBRARY SERVICES
 MEDICASH
 STAFF SUPPORT
 TRADE UNION
 FREEDOM OF INFORMATION
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
Corporate Trust Induction
DAY 2 - Conflict Resolution Workshop (ALL STAFF)
08.45 Registration
08.50 NLMS interactive session
Debbie Bradley
09.00 Conflict Resolution Workshop
Conflict Resolution Trainer
The importance of effective communication, recognising potential
difficult situations and how to respond
13.00 Induction Close
13.00 -13.30
LUNCH
Day 2:
PM - Introduction to Personal Care /Clinical refresher
Time table for clinical session: Direct care support staff and Direct care
Professionals only as indication below
Time
13.30 – 15.00
Direct care
support staff
pathway 2
Tissue Viability.
SPEAKER
Direct care professionals
pathway 3
15.00 – 15.15
Mary Harrison/
Tissue Viability
Sarah Oliver
Refreshment Break
15.15 – 15.45
Senior Pharmacist
Pharmacy
Andy Houghton
Blood Transfusion.
Deb Beswick-Cousins
HCA – Discussion of HCA role,
assisting patients with activities
of daily living via NQA tool.
Venous Thromboembolism
15.45 – 16.15
Programme
provided on day.
16.15 – 16.30
16.30 – 17.00
28
Solomon Almond/
Sue Pennington
PEF Team
Preceptorship and
planning your clinical Induction.
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Corporate Trust Induction
DAY 3 Manual Handling / CPR Practical
(Direct Care Support Staff and Direct Care Professionals only)
Location:
 Manual Handling - Training room, Lower Ground Floor (near loading bay) RLH
 CPR
TIME
8.45 Registration
9.00 – 12.00pm
13.30 – 16.30pm
- report to Reception, Education Centre RLH
SESSION
TRAINER
Falls Training and
Manual Handling Practical
Manual Handling Co-ordinator
CPR Practical Training
Arron Banks
Manual Handling (Dress code)
When attending the Manual Handling Practical session please ensure that you wear
appropriate clothing: non –slip enclosed shoes (no boots), and clothes that allow free
unrestricted movement.
Appendix 2
29
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Local Induction Workbook
INTRODUCTION
The Royal Liverpool and Broadgreen University Hospitals NHS Trust (RLBUHT) values the
contribution made by all staff in providing excellent care for our patients. We believe in a
structured approach to Staff Induction from your very first day in the Trust to support you
as a new member of our staff, and we also believe in your continued development during
your time with us through regular team brief and staff appraisal.
This Local Induction Workbook is the basic minimum standard for all RLBUHT staff. This
workbook should be used for all RLBUHT employed staff on either temporary or
permanent contracts. If you are not employed by the Trust, and working less than three
months, (e.g. if you are an Agency Worker, Locum staff, or on Work Experience etc.) you
should use the condensed version of this workbook, which must be completed before you
carry out any duties whatsoever. If you continue to work on RLBUHT premises for longer
than three months, then you should complete the full Local Induction Workbook, and you
may be required to attend the next available Corporate Induction Programme.
Upon completion of your local Induction as a permanent member of staff, your manager
must send a copy to Learning & Development Services, you keep a copy. For temporary
medical staff a copy is sent to Medical HR Services for non medical temporary staff a copy
is sent to the hospital bank.
Should you have any queries/difficulties, please contact Learning & Development
Services.
WHAT IS LOCAL INDUCTION?
“Local Induction” is information and supported learning in your Ward or Dept to introduce
you to your actual job. This will help you to get to know what you will be doing, and the
team you will be working with. The Corporate Trust Induction is a structured training
session about the most important aspects of our Trust relevant to everyone as new staff,
together with all the health and safety training relevant to your job role. You must
complete Local Induction directly following completion of the Corporate Trust Induction
programme; otherwise you will not know what is expected of you in your actual job! Some
Wards and Departments may include additional information to help you.
HOW IS LOCAL INDUCTION CARRIED OUT?
You will be allocated a “mentor” - someone assigned to support you in your job during your
first two weeks. If you are not informed who this will be, please ask your Line Manager.
During your Local Induction, you will observe others, attend meetings, visit other
Wards/Departments, discuss your role with various staff, and experience what it is like to
work alongside others in the team in your Ward/Dept.
Your Manager has responsibility for ensuring that Local Induction is in place for you. You
have responsibility for ensuring that it is completed. Your mentor and many other staff will
describe how things work and what you should do in certain circumstances, and will help
you along the way. If anything is unclear you must ask.
30
Royal Liverpool and Broadgreen University NHS Hospital Trusts
WHAT DO I DO WHEN THIS LOCAL INDUCTION WORKBOOK IS COMPLETED?
When you have worked through all the sections in the workbook, which may take one to
four weeks, ensure that the workbook is dated and signed. Your manager will send a copy
to Learning and Development and you should keep a copy for your records in your
Personal/Professional Portfolio.
WHAT HAPPENS AFTER I HAVE COMPLETED LOCAL INDUCTION?
There is a structured appraisal system in place at RLBUHT to help you continue to
develop in your job. Your Manager will explain how appraisal takes place, and your
responsibilities within appraisal.
You will also get involved in what’s happening, be asked for your ideas, and discuss how
any changes and improvements affect what you do in your job, and how you do it.
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
Local Induction Workbook (Permanent Staff i.e. All Trust employees)
Staff Name
Job Title
Ward/Department
Directorate/Corporate Service
Appointment date
When all parties are satisfied Local Induction has been completed, please sign below.
When completed please return to: Dept. No. 107, Learning and Development Department,1st Floor
Derwent House, Royal Liverpool Hospital, Prescot Street Liverpool L7 8XP
Date Trust Induction completed
Date Local Induction completed
Staff signature
Line Manager/Mentor signature
This workbook is to ensure that all aspects of your Induction are covered in a timely and effective manner.
As each item is discussed it will be signed off by the person providing the information, and by yourself, once
you feel the information has been adequately covered. If any item does not apply to your post please mark it
“N/A”. If you feel that any area has been missed, or you require further information, please bring it to the
attention of your line manager/mentor. Once Induction is complete, you and your line manager/mentor
should sign above. A copy will be kept by Learning and Development and you should retain a copy for your
records.
LOCAL INDUCTION - INTRODUCTION TO THE TEAM
Completed=
Date
Not applicable=N/A
1.
Welcome & introductions to the Ward/Dept/Directorate team
2.
Tour of the geographical layout of working area
3.
Tour of Trust premises, visiting departments relevant to
working area.
4.
Ward/Dept/Directorate management structure and reporting
arrangements. Name of :
Line Manager…
Equality & Human Rights Practitioner…
Learning Disability Champion…
Discussion about the main purpose of the team and how it
contributes to patient care.
5.



Aims, Vision and Values of the Trust
Directorate plans, targets and objectives
Where your team fits in
Providing a Quality Service:
 Promoting patient choice & customer service
 Handling patient/customer issues & problems
 How to use/access interpreting services
 Patient Advice & Liaison Service (PALS)
 Importance of patient confidentiality/case notes, data
protection
 Importance of confidentiality regarding staff
 Respecting equality and diversity ie. Expect Respect
campaign
 Safeguarding Children & who to contact with concerns
 Safeguarding Adults & who to contact with concerns
Infection Prevention & Control
 Hand hygiene
 Waste disposal
 Food Hygiene
 Procedures in work area
Risk Management
 Accident and incident reporting
6.
7.
8.
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Royal Liverpool and Broadgreen University NHS Hospital Trusts





9.
10.
11.
12.
13.
14.
15.
16.
33
Documentation & Incident form completion
First aid at work
Whistle blowing Policy
COSHH
RIDDOR
Emergency Procedures
 Who to contact in the case of an emergency
 Location of Resuscitation equipment and procedure
Communication systems and methods we use:
 Meetings
 Email
 Team Brief/Local Brief
 Intranet
 Trust Newsletters
 Communication events
 Handling the Press and other media
Understanding the telephone system:
 Telephone facilities
 Pagers/Bleeps
 Direct dialling
 Emergency Numbers
 Private calls
 Mobile phones
 Hearing Loop demonstrated (if applicable)
 How to make/receive calls via a textphone
Electronic Information
 Using the email system
 Training on systems relevant to your work
 Trust Intranet
 Use of Internet
 Data Protection/Information Governance
 Local Information Governance Lead and how to contact
SUPPORT FOR YOU IN YOUR JOB
Your working hours
 Rotas’/Shifts/flexibility
 Overtime/time owing/enhanced pay/flexi time
 Arrangements for Breaks and Dining Room facilities
 Requests for holidays/bank holidays
 Annual Leave entitlement/additions
 Special Leave
 Sickness reporting
 Doctors, Dentists, Personal Appointments
 What to do if you are ill at work
 Transport and travel – access to benefits
Dress and personal appearance
 The standard for the Ward/Dept
 Uniform arrangements
 Uniforms around the Trust – who’s who
 Wearing of Identity badges
Arrangements for Appraisal
 Appraisal system & how it works
 Appraisal Policy & documentation/Consultant Appraisal
 Your Job Description and/or Job Plan
Advice & support from Learning & Development
 Mandatory Training & responsibilities (see matrix)
 In-house Learning Directory & bulletins
 E learning/work based learning
 External Study Leave decisions
 Learning Contracts/Funding and time off
 Personal responsibility for learning
 Personal/Professional Portfolios
 Essential Skills – Adult Literacy/Numeracy/IT
Royal Liverpool and Broadgreen University NHS Hospital Trusts
24.
Advice & support from Human Resources (HR)
 Directorate/Corporate HR Business Partner role
 Important aspects of relevant polices – Sickness
Absence, Bullying & Harassment, Improving
Performance, Grievance, Disciplinary, Capability etc.
 Professional associations/Trade Unions
 Availability of Staff Networks
Advice & support from Occupational Health
 Your personal health and wellbeing responsibilities
 First aid at work e.g. Needlestick and body fluid injuries
 Referral process, staff support and guidance
 Counselling services
 Smoking Cessation Advice
Advice & support from Payroll and Pensions
 Arrangements for Pay/bank details
 Pension schemes
Advice & support from Security Services
 Security of Trust premises
 Reporting of attempted/actual breaches of security
 Personal security of self & belongings
 Lockers/other provision for storage of belongings
 Public Transport facilities
 Arrangements for Car Parking
Staff Benefits and Information
 Staff benefits facilities/discounted rates for Trust staff
 Child Care facilities, arrangements and activities
FIRE ORIENTATION CHECKLIST
This checklist is to be completed by all staff on their first
working day on the Ward/Unit/Dept.
Trust Fire Policy or applicable procedures (Evacuation
procedure, shut down procedure etc)
Local power, hazardous process and equipment isolation,
medical gas isolation points (if applicable)
An explanation as to fire safety signs and their meaning
25.
Break glass alarm point locations
26.
Locations of fire fighting equipment (extinguishers, fire
blankets etc)
Identify fire door locations i.e. fire doors to kitchen, store
rooms etc and ensure they are closed
Fire exit routes – locate and familiarize
17.
18.
19.
20.
21.
22.
23.
27.
28.
29.
Identify local methods/techniques of evacuation i.e. use of
beds, bed sheets, wheelchairs, evacuation equipment etc.
Utilisation of evacuation equipment (beds, evacuation mats
etc)
Additional local rules appertaining to fire safety (if applicable)
List below
SERVICE SPECIFIC INDUCTION
Additional sections to be added here if required
30.
31.
32.
33.
34.
Thank you for participating in Local Induction. We hope it was useful.
When completed please return to: Dept. No. 107, Learning and Development Department,1st
Floor Derwent House, Royal Liverpool Hospital, Prescot Street Liverpool L7 8XP
Appendix 3
34
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Local Induction Checklist (Temporary Staff )
Staff Name
Job Title
Ward/Department
Directorate/Corporate Service
Commencement date
When all parties are satisfied Local Induction has been completed, please sign below.
When completed please return to: Dept. No. 107, Learning and Development Department,1st Floor
Derwent House, Royal Liverpool Hospital, Prescot Street Liverpool L7 8XP.
Date Local Induction completed
Staff signature
Line Manager/Mentor signature
This workbook is to ensure that all aspects of your Induction are covered in a timely and effective manner.
As each item is discussed it will be signed off by the person providing the information, and by yourself, once
you feel the information has been adequately covered. If any item does not apply to your post please mark it
“N/A”. If you feel that any area has been missed, or you require further information, please bring it to the
attention of your line manager/mentor. Once Induction is complete, you and your line manager/mentor
should sign. A copy will be kept by Learning and Development and you should retain a copy for your
records.
The following must be signed off by Manager or representative prior to commencing duties:
EMPLOYMENT DOCUMENTATION CHECKS
Confirm an emergency contact telephone number
Identity Check (on ward/department)
Orientation to the ward/department and any areas within the
organisation relevant to post.
Security Pass, Key, name badge, access codes etc
Specific duties and responsibilities of the post
Confirm hours of work and shift patterns where applicable.
“On Call” and bleep arrangements.
Moving & handling procedures:
 Equipment
 Procedures
 Lifting and handling regulations
Resuscitation procedures:




Equipment
Procedures
Crash trolley location
Emergency telephone numbers
Medicines safety procedures:






35
Pharmacy and local protocols
Prescription
Administration
Standard operating procedures
Medications common to area
Completed=
Not applicable=N/A
Date
Royal Liverpool and Broadgreen University NHS Hospital Trusts
EMPLOYMENT DOCUMENTATION CHECKS
Completed=
Not applicable=N/A
Date
Completed=
Not applicable=N/A
Date
Incident reporting procedures:



Location of Incident forms
Completing the forms
Reporting arrangements
Infection control procedures:


Hand hygiene procedures
Infection status of clinical setting
Health and safety procedures:



Security
Waste disposal
VDU regulations
Any additional information essential to the Ward/Dept
FIRE ORIENTATION CHECKLIST
Trust Fire Policy or applicable procedures (Evacuation procedure,
shut down procedure etc)
Local power, hazardous process and equipment isolation, medical
gas isolation points (if applicable)
An explanation as to fire safety signs and their meaning
Break glass alarm point locations
Locations of fire fighting equipment (extinguishers, fire blankets etc)
Identify fire door locations i.e. fire doors to kitchen, store rooms etc
and ensure they are closed
Fire exit routes – locate and familiarize
Identify local methods/techniques of evacuation i.e. use of beds, bed
sheets, wheelchairs, evacuation equipment etc.
Utilisation of evacuation equipment (beds, evacuation mats etc)
Additional local rules appertaining to fire safety (if applicable) List
below
Thank you for participating in Local Induction. We hope it was useful.
Managers to send a copy to Learning and Development Services
NB:

36
If the individual will be working within the ward/department greater than three months the full
induction checklist (for Trust Employees) should be completed.
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Appendix 4
LOCUM / AGENCY RAPID INDUCTION PACK
This pack will be issued and its appendices completed by Human Resource Department within normal
working hours and by the Duty Managers outside of those hours.
Staff employed as locums from agencies will have a copy of “Medical Locum Rapid Induction Program” emailed to them from their agency.
Substantive locum appointments such as those which follow an advertisement and appointment procedure
involving HR & a Consultant will be issued this pack when they sign on with the HR department.
On Arrival at the Hospital RLH
DURING OFFICE HOURS:
 Go straight to the Medical Staffing Department on the Lower Ground floor at the rear of the Staff
Canteen.
OUT OF OFFICE HOURS:
 Go to switchboard on the first floor, turn left at the top of the escalator.
 You will be provided with a bleep and then you should ask how to contact the Duty Manager who
will need to see & speak to you if you have not worked at the hospital before.
 The Duty Manager will need to copy your Agency ID card or other photographic identification i.e.
Passport or photographic Driving Licence. You will also be given a copy of this information pack.
 You will need to sign a Trust confidentiality document & acknowledge
that you have received the Trust Rapid Induction document.
 If accommodation has been booked for you, you will be given directions of how to get to Prospect
Point where your accommodation is located.
On Arrival at the Hospital BGH
o
o
Report to the Security Office in the Alexander wing.
You will be provided with a bleep.
DURING OFFICE HOURS:
o
Ring switchboard on “0” to obtain the bleep from the doctor going off duty.
OUT OF OFFICE HOURS:
37
Royal Liverpool and Broadgreen University NHS Hospital Trusts
o
o
o
o
o
Bleep 4825 or ring Ext. 6838 to speak to the Duty Manager.
The Duty Manager will need to copy your Agency ID card or other photographic identification i.e.
Passport or photographic Driving Licence.
You will also be given a copy of this information pack.
You will need to sign a Trust Confidentiality Document & acknowledge
that you have received the Trust Rapid Induction Document..
If accommodation has been booked for you, you will be directed to your accommodation by
security.
Accommodation
o
Single room accommodation is available for locums for the duration of the locum contract, if
required.
o Accommodation should be arranged prior to your locum period through the Medical Staffing
Department..
o A charge of £32.00 per night is made, unless you are staying for over 10 nights when it is £14.46 per
night. These charges will apply for the whole of the stay regardless of whether you go home for
weekends or not.
o Accommodation must be booked and paid for in advance of arrival, if arrival is at short notice,
payment must be made to the Cash Office located on the 1st Floor, RLH.
o Keys are collected from Prospect Point.
o Any problems with accommodation please contact the Accommodation Manager on Ext.4107 in
office hours or the Duty Manager on Bleep 4200(Royal Site) or Bleep 4825(Broadgreen Site)
Catering RLH
o
There is a coffee shop, snack
bar and a WH Smith store on
the 1st floor podium at the top
of the escalator.
o
There is a staff restaurant on
the lower ground floor.
o
Out of hours there are snack
machines on the lower ground
floor within the staff canteen
area
WH Smith
Mon-Fri 08:00- 19:30
Sat & Sun 10:00- 17:00
Yoo Cafe
Mon-Fri 08:00- 19:00
Sat 11:00 -16:00
Sun 11:00- 16:00
Costa Coffee
Mon-Fri 08:00-17:00
Staff
Restaurant
Mon – Fri 07:30-11:00
1200-15:00
Catering BGH
Dining Room
Mon – Fri 07:30 – 15:00
Vending machines
17:00 onwards
WRVS
Alexander wing clinic
Monday – Friday 09:00 – 16:00
38
Royal Liverpool and Broadgreen University NHS Hospital Trusts
WRVS
Kent Lodge
Monday – Friday 12:00 – 16:00
Sat & Sun
Hospital Shop
New Build WRVS Shop and Cafe
16:00 – 19:00
Mon – Fri 0800 – 1800
Sat & Sun 11:00 - 17:00
Mon – Fri 08:00 – 19:30
Sat 12:00 – 19:30
Sun 10:00 – 15:30
Bleep System & Emergencies
If you are holding a Cardiac Arrest bleep you must hand it on to your successor NOT leave it with
switchboard.
 To bleep a colleague :
Lift receiver – dialling tone – 8 – 4 – then Bleep number – then your extension number. Wait for
verbal confirmation of connection before replacing the handset.
 Cardiac Arrest & Fire 2222
 Security 2200
 Duty Manager – outside office hours only, Bleep 4200 (Royal Site),
 Bleep 4825 (Broadgreen Site)
39
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Security
RLH
BGH
o
Several areas in the hospital have security
lockdown systems.
o
ID badges must be worn at all
times.
o
All have a buzzer which when pressed alerts the
ward / department area that someone requires
access and you will be “buzzed” in.
o
BGH Security can be contacted
on Ext. 6500
o
At a cardiac arrest or fire these doors will be
opened. Each of the doors has a green emergency
open button similar to a fire alarm button.
o
ID badges must be worn @ all times.
o
Security can be contacted on Ext. 2200
o
ID badges must be worn at all times
Handover
It is anticipated that you will attend handover on night shift. This is a meeting of medical and nursing staff
of the outgoing and incoming teams.
It is an opportunity to learn of issues which may arise through the night & the plans in place, meet the team
and agree priorities for each team..
RLH
BGH
Medicine
21:45hrs in AMAU Drs Office
(at the back of A&E)
Handover takes place at 9pm in Duty Managers
office.
Surgery 20:30hrs in Link 4Z (4th Floor)
Other Specialities & times bleep senior doctor for
area you are to cover (obtain number from
Switchboard)
The Nurse Practitioner (nights), 3 outgoing
SHO, 1 incoming SHO & the ODA attend.
Handover in the morning is doctor to doctor at
9am in the Doctors Mess.
You are not alone………..
Royal Liverpool Daylight shifts
o During the afternoon/evening shift and the Out of Hours period, i.e. from 14:00hrs each weekday
and all weekend & Bank Holidays one or two Senior Nurse Practitioners are on site to assist. They
can be contacted by bleep :
o Medical & Medical specialties 4221
o Surgery & Surgical specialties 4050
o A Medical Assistant is available on bleep 4937 to support you in performance of Cannulation &
Venepuncture.
o Bleep free breaks of 30mins / 4-6hrs for PRHO will be available by contacting the Nurse Practitioner
for your area.
40
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Royal Liverpool Night shifts
At night you will have the support of Senior Nurse Practitioners. They are allocated geographically:
2nd, 3rd & 4th Floors covered by bleep 4221
5th, 6th & 7th floors covered by bleep 4940
8th, 9th, 10th & 11th floors by bleep 4050
The Practitioners filter the PRHO bleeps from 2100hrs – 0700hrs.
A Medical Assistant is available on bleep 4937 to support you in the performance of Cannulation &
Venepuncture.
Bleep free breaks of 30mins / 4-6hrs for PRHO will be available by contacting the Nurse
Practitioner for your area.
Broadgreen Hospital
A Nurse Practitioner is on site 24/7 who provides both Clinical and Operational Support to the
Medical and Nursing staff. They can be contacted through Bleep 4825.
Pharmacy
o Access to a Pharmacist for advice is available 24/7.
o Out of Hours access is via the Duty Manager on bleep 4200 on the Royal Site or Bleep 4825
on Broadgreen Site.
o The pharmacy pages on the Trust Intranet include a National Formulary and ward stock
lists.
X-Ray
RLH site
X-Ray facilities are available 24/7
For special X-Rays (CT etc) you will need to contact switchboard who hold a rota for
Radiology Consultant, Registrar & Radiologist on call.
BGH site
In the event that a patient on this site requires an X- Ray an on call radiographer will be
brought in.
Patient Death
RLH site:
o PRHO is responsible for certifying death & informing the patients GP.
o RLUH - attend mortuary on next working day after death 0830-1000hrs
o Relatives should be advised to ring the Bereavement Office after 1000hrs on the next
working day following the death.
41
Royal Liverpool and Broadgreen University NHS Hospital Trusts
BGH site:
o SHO is responsible for certifying death & informing the patients GP.
o Attend General Office on next working day after death 0830-1000hrs
o Relatives should be advised to ring the Bereavement Office after 1000hrs on the next
working day following the death.
Guidance for Locum Doctors re obtaining
Password’s and Access to Trust Computer Systems
Locums attending for one/two Shifts:When a locum is only present in the Trust for one or two shifts it would be expected that their
colleagues would assist with the ordering of any investigations required.
Locums attending for an extended period of time:Any Locum attending for an extended period of time would be expected to contact the
Information Technology Training Department in order to obtain training and a password prior to
accessing any Trusts systems, as access to systems can only be enabled after training has been
given, access will not be enabled without training.
IT Training Department can be contacted on ext 3175
Locums, end of contract:It is the responsibility of the Locum to ensure that the Service Desk on Ext. 5499 is notified when
they leave the Trust, this enables the Service Desk to disable access to systems.
N.B. Due to the nature of the information that the Trust holds; it is essential that all data be
protected, and the sharing of passwords with others in strictly prohibited, any breach of this rule
may result in disciplinary action being taken. Under the Computer Misuse Act,1990. it is a
criminal offence to access or modify computer material without authorisation.
All Trust information Security and Data Protection Policies are
available via the Trust internet or via the Data Protection Office on Ext.
3671. The Duty Manager
The Duty Managers are a group of Senior Nurses with
vast Operational & problem solving skills.
Please feel free to contact them about any concerns
you may have during your stay.
IF IN DOUBT –
CALL THE DUTY MANAGER
Royal Site (Bleep 4200)
OR
THE NURSE PRACTITIONER
Broadgreen Site (Bleep 4825)
42
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Confidentiality Terms and Conditions of Employment
Your attention is drawn to the confidential aspects of working in the Royal Liverpool & Broadgreen
University Hospitals Trust.
In the course of hospital service you may see or hear things of a confidential nature including
information referring to the diagnosis and treatment of patients, and information relating to Trust
activity or in relation to other staff.
This information must not be divulged to, or discussed with any person other than relevant staff.
Breaches of confidence will result in the termination of your contract work with the Royal
Liverpool & Broadgreen University Hospitals NHS Trust.
The Trust will expect you to adhere to the principles laid down in various security and
confidentiality legislation with particular regard to Caldicott recommendations, the Data
Protection Act 1994, the Computer Misuse Act. Also attention should be paid to Trust’s own
Confidentiality and security policies and procedures, which can be found on the Trust Intranet.
No documentation is to be copied or removed from the Trust without the explicit permission of
the Data Protection Officer. You should also be mindful of the fact that regardless of any action
taken by the Trust, a breach of confidence could also result in a civil action for damages.
I__________________________(print name) have read and understood the above statement, and
I agree to be bound by the security and confidentiality policies and procedures of the Trust.
Signed__________________________________
Date____________________________________
Locum doctors arriving for duty
43
Royal Liverpool and Broadgreen University NHS Hospital Trusts
To be completed by Duty Manager / Nurse Practitioner.
Date & Time
Doctors Name
Tick box to acknowledge
that you have received & read the
Locum Rapid Induction Pack &
understand that it is your
responsibility to comply with the
information held within it.
Doctors signature
Photo ID seen
YES / NO
Grade
Agency
Name of Duty Manager / Nurse
Practitioner.
Signature of Duty Manager / Nurse
Practitioner.
Attach photocopy of locum’s ID to this sheet and send all 3 documents
FAO Lynn Kendall, Medical Staffing Dept. c/o Medical HR Dept. RLUH.
Appendix 5
44
Royal Liverpool and Broadgreen University NHS Hospital Trusts
F1 Induction
Programme
7 Day Programme
Education Centre RLUH
45
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Monday Day 1
**Venue for all sessions Lecture Theatre RLUH unless stated**
Time
8.30
Topic
Presenter
Registration Foyer Education Centre RLUH
8.45am
Welcome to the trust
Dr Weston
9.30
Fire Safety
Alan Raynor
10.15-11.00
Consent
Sally Cottrell
11.15-11.45
H&S, Security and
RM
Ronnie Jackson
11.45-12.30
VTE & MEWS
Solomon Almond
12.30-1.15
Lunch
1.15-1.30
Library
Angela Hall
1.30-2.15
Rotas, Medical
Staffing/ART
Dushyant
Sharma/Kay Carter
2.15 -2.30
2.30 3.45
3.45-5.00
3.45-5.00
46
CRT
Non Liverpool Grads: PSP: Aine McManus
Liverpool Grads: Identity Badges
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Tuesday Day 2
Time
8.30am
Topic
Registration foyer education centre
9.00-10.00
Your Role in the AMU
Simon Constable
10.00-10.30
Audit
Kiki Doran, Jenny
Poland and Chris
Ryall conf
10.30-11.00
Organ Donation
Liezl Gaum
11.00-11.15
11.15.-11.30
47
Presenter
break
CPR Summary
11.30-12.40
Information Governance
12.40-1.30
Lunch
1.30-5.00
Medicines Management
Jo Reed
Barbara
Smart/Peter
Williams
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Wednesday Day 3
Registration 8.30am Foyer Education Centre
Groups C & D
ALERT, Education Centre
RLUH
9-5pm
Groups A & B
Group
Training
session
A
IT
B
B
A
48
Venue
10TH Floor IT
Suite
CPR
Education
Centre
Lunch 12.00 – 13.30PM
Foyer, Education Centre
IT
10TH Floor IT
Suite
CPR
Education
Centre
Time
8.45-12.30
9.30 – 12.00
13.15 – 17.00
13.30-16.00
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Thursday Day 4
Registration 8.30am Foyer Education Centre
Groups A & B
ALERT, Education Centre
RLUH
9-5pm
Groups C & D
Group
Training
session
C
IT
D
D
C
49
Venue
10TH Floor IT
Suite
CPR
Education
Centre
Lunch 12.00 – 13.30PM
Foyer, Education Centre
IT
10TH Floor IT
Suite
CPR
Education
Centre
Time
8.45-12.30
9.30 – 12.00
13.15-5.00
13.30-4.00
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Friday Day 5
Time
8.30-915
Topic
Bereavement Services. Dave Lindale
9.15-10.00
Community
Assessment Team
Alan Cooper conf
10.00-10.45
Blood Transfusion
Peter Baker conf
11.00-12.00
Introduction to
Cardiology
Dr Michael Fisher
emailed 23/06, 01/07
12.00-12.45
Kidney Injury
Dr Rema Saxena
emailed 23/06, 01/07
12.45-13.45
50
Presenter
lunch
13.45-14.15
Introduction to
Surgery
Mr Nathan Howes
emailed 23/06, 01/07
14.15-15.15
Diabetes: clinical
scenarios
Dr Philip Weston
15.15-4.30
How to Survive as an F1
Dr Jayne Robinson et al
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Monday Day 6
Clinical Skills
Jo Marinas, Clinical Skills Training
Manager, and team
8.30am - 5.00pm
51
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Tuesday Day 7
Time
8.30
52
Topic
Presenter
Registration foyer education centre
8.45-10.15
E Portfolios
Do’s and Don’ts
Dr. Weston & F1
Doctor
representatives.
10.30-11.30
Abnormal Results: &
Fluid Management
Dr E Marks.
Consultant in Clinical
Chemistry
12.00-12.30
Oxygen Prescribing
Paul Deegan conf
12.30-1.30
Lunch
1.30-5.00
Handover and
shadowing in Clinical
area.
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Appendix 6
ST Induction
Wednesday Day 1
8.00-8.15
8.15-8.30
8.30-9.15
9.15-9.30
9.30-9.45
9.45-10.30
10.30 - 10.45
10.45-11.00
11.00-12.30
12.30-13.00
13.00-13.45
13.45-14.15
14.15-14.30
14.30-14.45
14.45 – 15.00
15.00 – 15.15
15.15-15.45
15.45 – 16.00
16.00 – 17.00
53
Welcome to the
Trust
Clinical Skills
Registration
Dr Weston, DPMGE
Jo Marinas, Clinical Skills
Training Manager
HR
Lynn Kendall, Senior HR
Officer
Fire Safety
Bill Fryer, Fire Safety
Manager
Consent
Dr Andrew Axon, Consultant
Intensivist
Library Service
Angela Hall, Library Manger
Counter Fraud
Darrell Davies (MIAA)
Counter Fraud Officer
Conflict Resolution Ronnie Jackson, Health and
Safety Training Manager
Lunch
Blood transfusion Karen Knowles MLSO 1
Safeguarding
Dave Roberts and Claire
Adults and
Pritchard, Safeguarding
Children
Leads
Resus Theory
Jo Reed, Resuscitation
Training Officer
Organ Donation
Rachel Brockley and Liezl
Gaum Eye Retrieval and
Tissue Donation Coordinators
ART
Jenny Bannon and Maria
Soumaroo Nurse
Practitioners
Investigation
Richard Wenstone
Incidents and
Consultant in ITU
Complaints
VTE
Vanessa Martlew, Consultant
Haematologist
Tissue Viability
Sarah Oliver, Tissue Viability
Nurse
Meds
Sally James
Management
Royal Liverpool and Broadgreen University NHS Hospital Trusts
ST Induction – Day 2/3
CPR/IT Training
Group is split to undertaken Training as per their skills need.
Skills passports are used to prevent repeat training
Groups identified to cover:






54
Information Governance (record Keeping)
CPR Training
IT Training
ID Badges
Complete E Learning
Join Clinical areas
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Appendix 7
F1 Teaching Programme
All F1 Doctors complete additional training in the first six weeks of employment to
continue their Corporate Induction.
The Topics covered include:
Medicines Management:
Anti Microbial Prescribing
Warfarin Prescribing
Prescribing in diabetes
Renal Disease and Drugs
Genetic Susceptibility to ADRs
Clinical
Knot tying and suturing – surgery
Knot tying and suturing – medicine
Liverpool Psychology Services for Cancer Patients
New ACS (Acute Coronary Syndrome) Guidelines
Medical Microbiology
Lumbar Puncture – MED ONLY
Case Presentations
General
Mental Capacity Act
Consent Forms 1 &2
Counter Fraud
Audit
55
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Appendix 8
Training Needs Analysis Matrix
The full training needs analysis can be found on the Trust Policy Website under Mandatory
Training – TNA – the summary below provides the groups and staff roles required to complete
training and the period of retraining.
Induction:
Once Only - All Staff employed for more than 3 months must attend Corporate Induction Pathway 1
– 5 in line with job roles as specified within this policy.
All permanent staff must complete the Local Induction Checklist as described in Appendix 2.
All temporary staff employed for less than 3 months must complete the Local Induction Checklist
as described in Appendix 3
All Locum/Agency Staff employed for one or more shift must complete the condensed Induction
Checklist as described in Appendix 4
Core Skills
Core Skills
Includes: Bullying & Harassment Policy Awareness, Counter Fraud, Equality, Diversity and Human Rights
Awareness, Fire Safety Awareness, Health, Safety & Security Awareness inc Slips, Trips & Falls
Management, Infection - Prevention and Control, Hand Hygiene and Inoculation, Information Governance &
Data Protection, Lone Worker Awareness, Manual Handling Awareness and Theory, Manual Handling - Safe
Lifting Inanimate Loads, Patient Safety - The Prevention of Falls, Risk Management Awareness, Safe
Guarding Children & Safe Guarding Vulnerable Adults
Update Required Every 2 Years
Staff Group
Add Prof Scientific and Technical
Additional Clinical Services
Administrative and Clerical
Allied Health Professionals
Estates and Ancillary
Healthcare Scientists
56
Role
Chaplain. Clinical Psychologist, Optometrist, Pharmacist, Practitioner,
Psychotherapist, Technician
Assistant Psychologist, Assistant/Associate Practitioner,
Assistant/Associate Practitioner (Nursing), Dental Surgery Assistant,
Health Care Support Worker, Healthcare Assistant, Helper/Assistant,
Medical Laboratory Assistant, Nursing Cadet, Student Technician,
Technical Instructor, Technician and Trainee Practitioner
Adviser, Analyst, Board Level Director, Chief Executive, Clerical Worker,
Finance Director, Librarian, Manager, Medical Secretary, Officer, Other
Executive Director, Personal Assistant, Receptionist, Secretary, Senior
Manager & Technician
Chiropodist/Podiatrist, Chiropodist/Podiatrist Specialist Practitioner,
Dietician, Dietician Manager, Occupational Therapist, Orthoptist,
Orthoptist Manager, Physiotherapist, Physiotherapist Manager,
Radiographer Diagnostic, Radiographer Diagnostic Consultant,
Radiographer Diagnostic Manager, Radiographer Diagnostic Specialist
Practitioner, Speech and Language Therapist, Speech and Language
Therapist Manager & Speech and Language Therapist Specialist
Practitioner
Assistant, Chargehand, Driver, Electrician, Housekeeper, Labourer,
Porter, Supervisor, Support Worker & Technician
Biomedical Scientist, Consultant Healthcare Scientist, Healthcare
Scientist & Technician
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Associate Specialist (Closed), Clinical Assistant, Clinical Director
Medical, Clinical Medical Officer, Consultant, Foundation Year 1 – 4,
General Dental Practitioner, General Medical Practitioner, Hospital
Practitioner, House Officer Post Registration Closed, House Officer Pre
Registration Closed, Salaried Dental Practitioner, Senior Dental Officer,
Specialty Doctor Specialty Registrar Closed, Specialist Registrar, Staff
Grade Closed, Trust Grade Doctor Career Grade Level & Trust Grade
Doctor Specialist Registrar Level
Community Nurse, Enrolled Nurse, Modern Matron, Nurse Consultant,
Nurse Manager, Sister/Charge Nurse, Specialist Nurse Practitioner &
Staff Nurse
Medical and Dental
Nursing Registered
Manual Handling Practical
Manual Handling - Practical use of equipment & devices
Update Required Every 2 years
Staff Group
Additional Clinical Services
Allied Health Professionals
Estates and Ancillary
Nursing Registered
Role
Assistant/Associate Practitioner, Assistant/Associate Practitioner Nursing,
Dental Surgery Assistant, Health Care Support Worker, Healthcare Assistant,
Helper/Assistant, Nursing Cadet &Technical Instructor,
Chiropodist/Podiatrist, Chiropodist/Podiatrist Specialist Practitioner, Dietician,
Dietician Manager, Occupational Therapist, Physiotherapist, Physiotherapist
Manager, Radiographer Diagnostic, Radiographer Diagnostic Consultant,
Radiographer Diagnostic Manager, Radiographer Diagnostic Specialist
Practitioner, Speech and Language Therapist, Speech and Language
Therapist Manager & Speech and Language Therapist Specialist Practitioner
Chargehand
Community Nurse, Enrolled Nurse, Modern Matron, Nurse Consultant, Nurse
Manager, Sister/Charge Nurse, Specialist Nurse Practitioner & Staff Nurse
Basic Life Support (Adult) Resuscitation
Basic Life Support (Adult)/Resuscitation
Required Every 2 Years
Staff Group
Add Prof Scientific and
Technical
Additional Clinical Services
Allied Health Professionals
Estates and Ancillary
Medical and Dental
Nursing Registered
57
Role
Optometrist & Technician,
Assistant/Associate Practitioner, Assistant/Associate Practitioner Nursing,
Dental Surgery Assistant, Health Care Support Worker, Healthcare Assistant,
Helper/Assistant, Nursing Cadet, Technical Instructor & Technician
Chiropodist/Podiatrist, Chiropodist/Podiatrist Specialist Practitioner, Dietician,
Dietician Manager, Occupational Therapist, Orthoptist, Orthoptist Manager,
Physiotherapist, Radiographer Diagnostic, Radiographer Diagnostic
Consultant, Radiographer Diagnostic Manager, Radiographer Diagnostic
Specialist Practitioner, Speech and Language Therapist, Speech and
Language Therapist Manager & Speech and Language Therapist Specialist
Practitioner
Chargehand
Associate Specialist (Closed), Clinical Assistant, Clinical Director Medical,
Clinical Medical Officer, Consultant, Foundation Year 1, 2, 3 & 4, General
Dental Practitioner, General Medical Practitioner, Hospital Practitioner,
House Officer Post Registration Closed, House Officer Pre Registration
Closed, Salaried Dental Practitioner, Senior Dental Officer, Senior House
Officer Closed, Specialist Registrar Closed, Specialty Doctor, Specialty
Registrar, Staff Grade Closed, Trust Grade Doctor Career Grade Level &
Trust Grade Doctor Specialist Registrar Level Closed.
Community Nurse, Enrolled Nurse, Modern Matron, Nurse Consultant, Nurse
Manager, Sister/Charge Nurse, Specialist Nurse Practitioner & Staff Nurse
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Clinical Core Skills
Clinical Core Skills
Includes: Medicines Management, Tissue Viability, Blood Transfusion Awareness,
Venous Thromboembolism Awareness
Update Required Every 2 years
Staff Group
Role
Nursing Registered
Community Nurse, Enrolled Nurse, Modern Matron, Nurse Consultant,
Nurse Manager, Sister/Charge Nurse, Specialist Nurse Practitioner & Staff
Nurse
Conflict
Conflict Resolution National Syllabus/Violence & Aggression Training
Update Required Every 3 years
Staff Group
Add Prof Scientific and
Technical
Additional Clinical Services
Administrative and Clerical
Allied Health Professionals
Estates and Ancillary
Medical and Dental
Nursing Registered
58
Role
Optometrist & Technician,
Assistant Psychologist, Assistant/Associate Practitioner,
Assistant/Associate Practitioner Nursing, Dental Surgery Assistant, Health
Care Support Worker, Healthcare Assistant, Helper/Assistant, Nursing
Cadet, Technical Instructor & Technician
Clerical Worker, Manager, Officer, Receptionist & Senior Manager
Chiropodist/Podiatrist, Chiropodist/Podiatrist Specialist Practitioner,
Dietician, Dietician Manager, Occupational Therapist, Orthoptist, Orthoptist
Manager, Physiotherapist, Physiotherapist Manager, Radiographer
Diagnostic, Radiographer Diagnostic Consultant, Radiographer Diagnostic,
Manager, Radiographer Diagnostic Specialist Practitioner, Speech and
Language Therapist, Speech and Language Therapist Manager & Speech
and Language Therapist Specialist Practitioner
Chargehand & Support Worker,
Associate Specialist Closed, Clinical Assistant, Clinical Director Medical,
Clinical Medical Officer, Consultant, Foundation Year 1 – 4) General Dental
Practitioner, General Medical Practitioner, Hospital Practitioner, House
Officer Post Registration Closed, House Officer Pre Registration Closed,
Salaried Dental Practitioner, Senior Dental Officer, Senior House Officer
Closed, Specialist Registrar Closed, Specialty Doctor, Specialty Registrar,
Staff Grade Closed, Trust Grade Doctor Career Grade Level & Trust Grade
Doctor Specialist Registrar Level Closed
Community Nurse, Enrolled Nurse, Modern Matron, Nurse Consultant,
Nurse Manager, Sister/Charge Nurse, Specialist Nurse Practitioner & Staff
Nurse
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Consent
Consent Training
Required Once Only
Staff Group
Medical and Dental
Nursing Registered
Role
Associate Specialist (Closed), Clinical Assistant, Clinical Medical Officer,
Foundation Year 1, 2, 3 & 4, General Dental Practitioner, General Medical
Practitioner, Hospital Practitioner, House Officer Post Registration Closed,
House Officer Pre Registration Closed, Salaried Dental Practitioner, Senior
Dental Officer, Senior Dental Officer Closed, Specialist Registrar Closed,
Specialty Doctor, Specialty Registrar, Staff Grade Closed, Trust Grade
Doctor Career Grade Level & Trust Grade Doctor Specialist Registrar Level
Closed
Nurse Consultant
Investigation of Incidents, Complaints and Claims (RCA)
Root Cause Analysis
Required Once Only
Staff Group
Role
Administrative and Clerical
Nursing Registered
Directorate Manager, Assistant Directorate Manager
Directorate Manager, Assistant Directorate Manager & Modern Matron
59
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Appendix 9
Core Skills Update
Programme
08.45 Registration & Refreshments
09.00
Core Skills – every 2 years
Counter Fraud
09.15
Risk Management, Health, Safety & Security
09.45
Fire Safety
10.15
Infection Control
10.45
Information Governance
11.15
Refreshment break
11.30
Safeguarding Children & Vulnerable Adults
12.00
Manual Handling – safe practice reminder, inanimate load update
12.30
Lunch Break
13.30
Clinical Skills Refresher (patient facing professionally qualified staff)
End of Life Care (not mandatory)
14.00
Medicines Management
14.30
Tissue Viability
15.00
Blood Transfusion
15.30
Mentorship (not mandatory)
16.00
Dieticians (not mandatory)
16.30
VTE
All Staff identified within the TNA (Appendix 7) are required to attend “Core Skills
Update” every 2 years. Patient facing professionally qualified staff** remain for the
afternoon, or do a split half day every year if more appropriate.
In addition to the above all staff who work in patient areas (qualified and unqualified
including administrative staff**) are required to attend a ½ day Conflict Resolution
Workshop every 3 years, and patient facing staff (qualified and unqualified direct care
staff) are required to attend appropriate resuscitation training
** See Mandatory Training Matrix (appendix 7) for detail.
60
Royal Liverpool and Broadgreen University NHS Hospital Trusts
Appendix 10 Equality Impact Assessment Tool
Yes/No
1.
Comments
Does the policy affect one group
less or more favourably than
another on the basis of:

Race

Ethnic origins (including gypsies No
and travellers)

Nationality
No

Gender
No

Culture
No

Religion or belief
No

Sexual
orientation
including No
lesbian, gay and bisexual people

Age
No

Disability
No
No
2.
Is there any evidence that some No
groups are affected differently?
3.
If you have identified potential None
discrimination, are any exceptions
valid, legal and/or justifiable?
4.
Is the impact of the policy likely to No
be negative?
5.
If so can the impact be avoided?
6.
What alternatives are there to N/A
achieving the policy without the
impact?
7.
Can we reduce the impact by N/A
taking different action?
Part-time night staff. Flexible start
times to enable night staff to
complete Mandatory & Local
Induction training.
N/A
If you have identified a potential discriminatory impact of this policy, please refer it to the
Equality and Diversity Manager together with any suggestions as to the action required to
avoid/reduce this impact.
61