Training Service Accreditation: Guidance for Training Managers

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1 Training Service Accreditation: Guidance for Training Managers Author: Training Quality Improvement Team Date: 27/02/15 Version Copyright 2015, Health and Social Care Information Centre.

2 Contents 1. Purpose 3 2. Overview of the TSA Process 3 3. Getting started 4 4. Memorandum of understanding 4 5. Costs 5 6. What evidence should I upload? 5 7. How do I know I m ready to submit an assessment? 7 8. What happens next? 7 9. Pre-Site Visit Report What happens at the site visit? After the site visit Temporary Release Final accreditation report What happens if I don t agree with the final accreditation level? Appeals Complaints Reaccreditation Improving your processes Where to get help Improving the TSA scheme Supporting materials Glossary Contact Us 12 2 Copyright 2015, Health and Social Care Information Centre.

3 1. Purpose This step by step guide will explain everything you need to do to complete your Training Service Accreditation (TSA). This scheme is run by the Training Quality Improvement (TQI) team from the Health & Social Care Information Centre (HSCIC). 2. Overview of the TSA Process 1. You will begin the process completing your self-assessment against the eight national E&T Standards using our dedicated online benchmarking application (ESOBA). You will use this application to assess your current level of achievement and upload evidence or add supporting comments for each requirement you meet in support of your selfassessment. 2. Once you are satisfied you have reached the level you would like to be assessed at, you can then request a formal TSA assessment and a TSA Assessor will be allocated to carry out your assessment 3. You will be contacted to agree a date for a site visit. Once this has been confirmed you will receive a copy of a memorandum of understanding for you to sign and return. 4. The TSA Assessor will review the online self-assessment and supporting evidence and submit a preliminary report to you no less than 10 working days before the site visit. 5. This report (the Pre-Site Visit Report), will provide you with a preliminary level of assessment, based on the assessment and evidence / supporting comments you have submitted. This level may be lower than your own self-assessment level. The TSA Assessor will highlight areas that they will wish to discuss with you during the site visit which may include visiting the training facilities, meeting some of the trainers and the training administrator. The TSA Assessor may also identify where additional evidence is required for you to meet a requirement, if what you have uploaded is not sufficient. The pre site visit report gives you an opportunity to prepare any additional evidence that might be required, including putting processes in place or updating documentation. 6. At the site visit, the TSA Assessor works with you to identify both where your service is doing well and areas where improvements could be made. You may agree a 3 Copyright 2015, Health and Social Care Information Centre.

4 development plan with the TSA Assessor during this visit if there are areas where you need to make improvements or submit further evidence in support of TSA. 7. The TSA Assessor is able to re-open your assessment for a period of 24 hours in order to allow you to upload additional pieces of evidence. The TSA Assessor will agree this date with you, which will be within 10 working days of your site visit. The TSA Assessor will then review the new evidence and produce the final accreditation report. 8. Following the visit or the temporary release, you will receive a final accreditation report within 10 working days, with recommendations and follow-up actions where necessary and a decision on the level of accreditation. 9. When you receive the final accreditation report you will also receive a final accreditation report acceptance form. This is for you to return by to indicate that you accept the level awarded by the TSA Assessor. 10. Once your acceptance has been received by an invoice will be generated and sent. It is also possible to be invoiced up front before the visit takes place if required. 11. Once the invoice has been paid a certificate will be sent to you. The certificate will include your re-accreditation date, two years later. You will also be sent the TSA quality mark that you can use on your training materials, website and signatures. 3. Getting started 1. Register for the E&T Standards online benchmarking application (ESOBA), via the ESOBA web pages. 2. Download the registration form. Once you ve completed the form, send it to 3. You will then be contacted by a member of the Training Quality Improvement (TQI) team who will set up a convenient time to provide a 30 minute remote training session using our training environment. You will learn how to use ESOBA, complete an assessment and upload supporting evidence. 4. Once the training is complete, you will receive your ESOBA login within 2 working days. 5. You can then complete your assessment, by answering Yes, No or Not Applicable to the requirements which make up the 8 E&T Standards. For any requirement where you have answered Yes, you must either provide further explanation via the comments field or upload supporting evidence (see next section for examples of evidence you can submit). 4. Memorandum of understanding Once you have decided that you wish to complete TSA and you have started to look at dates for the site visit, you will be sent the TSA memorandum of understanding (MOU). This is an agreement of what services will be provided, the agreed costs and timescales. This should be signed and sent back to the TQI team at the address at the end of this document. 4 Copyright 2015, Health and Social Care Information Centre.

5 5. Costs Costs (excluding travel expenses which will be charged at cost): 1600 for the assessment plus travel expenses Optional consultancy will be charged at a cost of 500 per day or 70 per hour plus travel expenses. 6. What evidence should I upload? When choosing evidence to submit with your assessment, bear in mind that the TSA Assessor will be looking for examples of where you feel you meet a requirement, rather than uploading every single piece of evidence that you feel is relevant. A maximum of three pieces of evidence can be uploaded for any requirement. You can also link the same evidence to different requirements, where relevant. The TQI team provides the following documents to support you: A guidance document outlining what types of evidence to upload. Evidence statements for those requirements which may be more difficult to provide actual documents for. These documents will be provided by the TQI team. There are also some examples on the evidence list below. The list is not exhaustive, but is there to provide some guidance on the types of evidence that you may consider uploading as part of your assessment. Evidence may be in various formats, e.g. word documents, scanned documents or pictures, photographs, copies of s, screenshots or process maps. These are only examples of evidence that you might want to upload. Please refer to the evidence guidance for full explanation of what needs to be uploaded for each requirement. Please note that there is a size limit of 4MB per document uploaded to ESOBA. There is also an upload limit of 3 documents per requirement. Document templates for each standard are embedded in the E&T Standards guidance document. For example, if you don t have a training strategy, you can use the template within the E&T Standards guidance documents. This template will provide you with a structure and also give guidance about what to include in each section. Examples of evidence that might be used for each standard may include: E&T Standard Example evidence 1. Training Service An up to date Training Strategy document which covers all the Strategy services you provide. It should be signed off by relevant stakeholders. 2. Training Plan 1 or 2 examples of training plans you have used in the past Learning Needs Analysis (LNA) 4. Training Service Administration months for a project or for business as usual training. 1 or 2 examples of LNAs you have carried out in the past 12 months e.g. a basic IT skills or role-based training LNA. LNA results which show how these have been incorporated into your training programme or a LNA report. Processes and documented procedures you use to book and manage training courses and evidence of how it is 5 Copyright 2015, Health and Social Care Information Centre.

6 5. Training Materials and Delivery 6. Evaluation and Assessment communicated to the rest of the training team. Copies of s sent to attendees with joining instructions. Screenshots of your learning management system if you use one. Evidence to show that you keep training records securely. Examples of reports with detail of frequency and types of management reports. Examples of different types of training materials you use in the delivery of training: Evidence of materials being created, reviewed and stored appropriately. For example, the process for creation and review of training materials with stakeholder involvement. Evidence to show how materials have been updated following feedback from stakeholders or via end of course evaluations. Version control of training materials, compliance with copyright and information governance. Course outlines, lesson plans, quick reference guides, user guides. Screenshots of any elearning packages you use. Post course evaluations (e.g. happy sheets and competency tests). End user assessments and results. Information on processes you have in place for evaluating the effectiveness of the training you are delivering. Evaluation report with recommendations for changes to the training. 7. Facilitator Performance Development Reviews (PDRs) - which you may want to anonymise. Evidence of protected learning time (team meeting minutes, L&D policy, etc.). Copies of your trainers qualifications. CVs of trainers. Job descriptions to show person specification. Peer observation. 8. Facilities and equipment Photos and/or plans of training rooms and their layout. Risk assessments carried out on training rooms. Instructions for use of equipment. Contingency plans, e.g. in case of a technical fault. Renewal policy. Remember you can link more than one requirement to a single piece of evidence. If you find there are things missing, you should look at this as a process to highlight gaps where your training service may need to improve. There may be some processes that you need to improve or put in place, or there may be processes or procedures that are already in place, but you have to document. For example, you and your team may follow a process for administering your training service, but to meet the Training Service Administration standard, you may need to write up the process as evidence. 6 Copyright 2015, Health and Social Care Information Centre.

7 If you feel like there are certain areas where you need more support and guidance to improve, for example if you haven t got any evaluation or assessments in place, the TQI team can provide tailored on-site or remote support. This type of help will fall under the TQI consultancy service, which is chargeable. 7. How do I know I m ready to submit an assessment? You will be ready to submit when you have the following in place: You have completed the attained field (Yes/No/Not Applicable) for each requirement in all five levels on ESOBA. Your self-assessment has been calculated to the minimum level you want to achieve. Each requirement where the attained level has a Yes against it, has at least one piece of evidence uploaded, or a detailed supporting comment/evidence statement to support it. You have demonstrated that where relevant, as well as having a process in place, you have actually put it into practice. Once you are happy that you have achieved the above you need click the Register for TSA button on the ESOBA Home Screen, this will send an informing you that the TQI team will contact you. (If you have already clicked this at an earlier stage then please contact the TQI team when you are ready to submit.) A member of the TQI team will check that sufficient evidence and supporting comments have been uploaded before they will allow you to submit your assessment on ESOBA. After the checks have taken place, you will be able to click the Submit for Assessment button to change the status of your assessment to Submitted for Assessment. Once you have submitted your assessment, ESOBA changes the status to read-only and you will no longer be able to make changes. 8. What happens next? Once you have submitted your assessment, you will receive an notification to confirm that it has been received. A member of the TQI team will then contact you to discuss your submission and allocate a TSA Assessor within 10 working days of your submission. The TSA Assessor will contact you within 10 days to agree a date for your site visit and provide you with their contact details should you have any questions, prior to the site visit. 7 Copyright 2015, Health and Social Care Information Centre.

8 9. Pre-Site Visit Report Approximately 10 working days before your site visit is due to take place, you will receive a pre-site visit report from your TSA Assessor. This report will contain a preliminary assessment level, general comments on your assessment, the supporting evidence you provided and suggestions for further evidence to be provided. The TSA Assessor will provide an outline agenda for the site visit, as he/she may want to visit your training rooms or meet members of the training team or end users. The pre-site visit report is intended to prepare you for the types of questions that will be asked and where applicable, any additional evidence you need to prepare and provide at the site visit. If you have any questions relating to this report then you should direct these to your TSA Assessor. 10. What happens at the site visit? The TSA Assessor will usually ask you to book out a whole day to complete your site visit. The site visit usually lasts between 3 to 6 hours (up to a maximum of 7.5 hours). During the site visit, the TSA Assessor will go through your assessment and each section of the pre-site visit report with you, to address the points they highlighted during the review of your assessment. This will be an opportunity for you to present any new or updated evidence that you have prepared. The TSA Assessor may also pick out further points for development or identify areas where you are performing particularly well. He/she may ask whether evidence you have provided may be shared and used by other training services. This will only be done with your permission. The TSA Assessor will ask to see a training room and may wish to speak to members of the training team or end users. They may also want to sit in and observe part of a training session being delivered. 11. After the site visit 5 working days after the site visit, you will receive the notes of the visit and actions to complete, some of which may be to upload additional pieces of evidence during a temporary release: 11.1 Temporary Release The TSA Assessor is able to re-open your assessment for a period of 24 hours in order to allow you to upload additional pieces of evidence. The TSA Assessor will agree this date with you, which will be within 10 working days of your site visit. The TSA Assessor will then review the new evidence and produce the final accreditation report. 8 Copyright 2015, Health and Social Care Information Centre.

9 11.2 Final accreditation report The TSA Assessor will complete a Final Accreditation Report and send to you within 10 working days of the visit or temporary release (whichever is applicable). The accreditation level in this report is their final decision as to what level you have achieved. If you are in agreement with the final accreditation report, you will be asked to fill in an acknowledgment form and send back to the TQI team within 10 working days. Once this is received, an invoice will be generated and sent to you. When this is settled (within 30 days), the TQI team will then send you the TSA Certificate and quality mark for you to use. If however, you do not agree with the accreditation report, you will need to appeal against the decision. Your accreditation is valid for 2 years, but if you wish to, you do have the option of reaccrediting sooner, for example, if your service had been working towards the next level and is ready to be reassessed before the end of the 2 year period. 12. What happens if I don t agree with the final accreditation level? 12.1 Appeals If, when you receive the final report you do not agree with the TSA Assessor s decision, then you can appeal against their decision. You will be required to put your reasons for appeal in writing, within 10 working days of the date the Final Assessment report was sent to you. Please to request a copy of the procedure and form. Once your appeal has been received, the reasons will be considered by a panel of NHS training professionals. You may be requested to attend a meeting of the panel in order to explain the circumstances and reasons for the appeal. The panel will consider the circumstances and reasons raised and based on those facts, will make a decision. Depending on the outcome of the panel, your submission may be re-assessed by a different TSA Assessor. The decision made by the appeals panel will be given in writing to the Training Service Manager within 30 working days of receipt of the appeals form and are final. Representatives on the panel will include: A representative from the Training Quality Improvement team (not the original assessor). A Training Service Manager (not linked in any way to the original assessment). A member of the TQI National Reference Group 12.2 Complaints Please contact the TQI team if you have a complaint about the TSA service, as we take all complaints very seriously. We will acknowledge your complaint within 3 working days and respond within 20 working days. All complaints are dealt with in the strictest confidence. 9 Copyright 2015, Health and Social Care Information Centre.

10 However, if your complaint relates to the TSA assessment outcome or the TSA assessment process, please refer to the Appeals section above. You will be required to put your reasons in writing within 20 days of the date of the incident you wish to raise a complaint about. Please contact to request the complaints form and procedure. To help us investigate your complaint, please provide us with as much information as possible when you contact us, and in particular, give us a clear description in writing of the reasons for your complaint. Then send your completed form to us by to If we cannot respond in full within 20 days following our investigation, we will explain why and give you a date by which you can expect a full reply. Responses and the outcome of the complaint investigation will be given to you in writing and are final. 13. Reaccreditation TSA is awarded for a 2 year period from the date of the site visit. The TQI team will send you a reminder 6 months before your current accreditation expires. You will need to complete a re-assessment before your accreditation expires to maintain a valid accreditation. It is possible to reaccredit within the 2 year period if you wish. You should also complete a reaccreditation within the 2 year period if your training service has changed significantly, for example, you have: moved into a new organisation merged with an organisation that has never been accredited or is accredited at a lower/higher level than you a new training manager or; self-assessed to a higher level. 14. Improving your processes The primary purpose of TSA is to highlight areas where your service can be improved, so don t worry if going through this process identifies gaps. The E&T Standards Guidance will help to provide you with tips on meeting the requirements. Your TSA Assessor will also be able to provide you with practical tips and guidance during the site visit. 10 Copyright 2015, Health and Social Care Information Centre.

11 15. Where to get help If you are confused about any aspect of TSA or completing your assessment, then please contact a member of the TQI team who can provide further assistance. Contact details can be found on the last page of this document. 16. Improving the TSA scheme We evaluate the TSA scheme at all stages with both the training services and the TSA Assessors. The TQI National Reference Group evaluates this feedback which is then integrated into the overall scheme. We also capture feedback from training services that use the E&T Standards and the online benchmarking application. The national Standards Review Group reviews and considers all feedback for inclusion in the annual review of the E&T Standards. After you receive your final accreditation report you will receive an evaluation form from the TQI team. It is really important to us that you complete this and send it back to us at so that we can improve the TSA process. 17. Supporting materials Supporting materials for this process: Supporting Material E&T Standards & Guidance What it covers E&T Standards, Requirements and accompanying guidance 18. Glossary BAU E&T ESOBA ETD HSCIC LNA TQI TSA Business as usual Education & Training E&T Standards Online Benchmarking Application Education, Training and Development Health and Social Care Information Centre Learning Needs Analysis Training Quality Improvement Training Service Accreditation 11 Copyright 2015, Health and Social Care Information Centre.

12 19. Contact Us You can find further information about Training Service Accreditation, the E&T Standards and our online benchmarking application: On our website: Or Or write to us at: Training Quality Improvement Team Health and Social Care Information Centre Ground Floor 1 Trevelyan Square Boar Lane Leeds LS1 6AE Senior Project Manager- Training Service Accreditation Jenny Craggs Phone: E&T Standards & Online Benchmarking Application Support: James Aubery Phone: or Head of Training Quality Improvement: Carole Sheard Phone: or Copyright 2015, Health and Social Care Information Centre.

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