Mandatory Training Summary of Requirements - September 2013

. Safeguarding Children Conflict Resolution Statutory - Children Act 1989 and 2004 Every Child Matters 2003 'Working Together to Safeguard Children' 2010, HCSA Reg 11, Safeguarding Children and Young People: Roles and Competencies for Health Care Staff Intercollegiate Document ( DoH 2006) Statutory - Secretary of State - CFSMS National Syllabus, HSCA Reg 11, NHSLA Standard 3 Safe Environment - Criterion 9: Violence & Aggression. NHSLA TNA Minimum Data CQC Outcome 7 - focuses on safeguarding people who use services from abuse and requires the Trust to "ensure that Government and local guidance about safeguarding people from abuse is accessible to all staff and put into practice." In particular the Trust needs to minimise the risk and likelihood of abuse occurring. Risks Include: Harm, injury or death to a child. Trust reputation. Professional Reputation and dismissal. CQC Outcome 7 focuses on safeguarding people who use services from abuse and requires the Trust to protect others from the negative effect of any behaviour by people who use services. CQC Outcome 14 requires the organisation to ensure staff are properly trained and specifically that there are "clear procedures followed in practice, monitored and reviewed, that are implemented when staff are subject to violence, harassment or bullying by other staff or people who use services. Child Protection Group 1 Child Protection Group 2 Child Protection Group 3 Admin & Clerical Staff in clinical teams, Managers, AHP's and Pharmacists. Healthcare Assistants and Allied Health professional Assistants in Inpatients, Volunteers, Temporary workers in the above settings Staff in regular/intense irregular contact with children/paprents: Qualified nurses, Social workers, Psychologists, Allied Health Professionals, Doctors, Counsellors, CARAT workers, Community HCAs & AHP Assistants, DNLD HCA's For all staff who work predominantly with children, young people and their parents/carers who require more specific training. These are staff working in Children s Services, Perinatal Services, Community Specialist Support Team, qualified staff in Early Intervention Teams, Crisis Resolution Teams, Community Mental Health Teams and Social Workers. On appointment/once - A&C Staff, Managers, AHP's, Pharmacists. On appointment and then 3 yearly HCA s and AHP Assistants in Inpatients, Volunteers, Trust Induction. E-, (Workbook for, Mgrs, Pharmacists) 3 yearly 3 yearly min. Annually recommended. Conflict Resolution Training - Non clinical staff Admin & Clerical. Corporate Services. Managers. Promoting Safer and Therapeutic Services (Included in MAPA training) All Clinical Staff, Doctors, All CARATS Workers, All Social Workers Equality and Diversity Statutory - Equality Legislation HSCA Reg 17 CQC Outcome 1, Requires staff who work in the Trust to "recognise the diversity, values and human rights of people who use services CQC Outcome 25 requires registered persons to "uphold and promote the rights and meet the diverse needs of people who use their service and follow current legislation" Risks include: Breach of Equality legislation. Trust reputation. Discrimination/Harassment claims. Equality and Diversity All employees, Registered Managers, Trust Induction, E-, Workbook Equality Impact Assessment Nominated persons Once then as required. Fire Safety (Local Procedures) Level 1 All employees on first day of employment as part of local induction checklist Once on appt. Fire Safety Basic Instruction Level 2 All Employees working in non ward-based areas 2 Yearly, E- Fire Safety Statutory - HASWA & Fire Safety Order 2005 HSCA Reg 15 CQC Outcome 10, Focuses on the Safety & Suitability of premises and requires the Trust to make sure that people who use services and people how work in or visit the premises are "in safe, accessible surroundings that promote their well-being, are protected against the risk of unsafe or unsuitable premises, and are compliant with any legal requirements". Risks include: Loss of life. Property loss. Corporate Fire Safety Instruction and Evacuation Level 3 All Employees working in ward-based areas Yearly Face to Face 1

Manslaughter/Prison sentences. Heavy financial penalties to organisation Fire Safety for Fire Wardens/Fire Marshalls Employees nominated as fire wardens/fire marshals in ward-based areas 3 Yearly. Fire Safety for Directors and Senior Persons Registered Managers 2 Yearly. Health and General Awareness (includes Risk Management level 1, Slips, trips & falls) Display Screen Equipment (VDU Risk Assessment) All employees, Registered Managers 3 Yearly initial training as part of induction, Updates by e- All Managers. Nominated persons 3 Yearly E- Health & Safety Statutory - HASWA, The Management of Health and Safety at Work Regulations 1999, HSCA Reg 15, NHSLA Standard 1 Governance Criterion 4: Risk Awareness Training for Senior Management, NHSLA Standard 3 Safe Environment Criterion 1: Secure Environment & Criterion 5: Slips, Trips & Falls CQC Outcome 10 focuses on the Safety & Suitability of premises and requires the Trust to make sure that people who use services and people how work in or visit the premises are "in safe, accessible surroundings that promote their well-being, are protected against the risk of unsafe or unsuitable premises, and are compliant with any legal requirements".cqc Outcome 11 focuses on safety, availability and suitability of equipment and requires the Trust to ensure people "are not at risk of harm from unsafe or unsuitable equipment" Risks include: HASWA breached. HSE Improvement notice. Risk to Health. Sickness absence. Possible litigation and compensation claims. First Aid Appointed Persons Appointed persons 3 Yearly First Aid At Work Appointed persons Once First Aid At Work Refresher Appointed persons 3 Yearly Risk Management Level 1 All employees 3 Yearly initial training as part of induction, Updates by e- Risk Management HSCA reg 17, HSCA Reg 10, NHSLA Standard 2 Competent & Capable Workforce - Criterion 7: Clinical Risk Assessment, NHSLA TNA Minimum Data CQC Outcome 2 focuses on consent to care and treatment and requires the Trust to "manage risk through effective consent procedures". Outcome 16 focuses on assessing and monitoring the quality of service provision and requires the Trust to "identify, monitor and manage the risks to people who use, work in or visit the service" and "improve the service by from adverse events, incidents, errors and near misses" Risks include: Harm or death to patients. Litigation. Poor clinical practice Risk Management Level 3 Clinical Risk Management Level 2 Registered Managers. Service Managers. Ward Managers & Team Leaders (band 7) All Qualified Nurses, Social Workers & AHPs, All Psychologists, Pharmacists & Doctors, All clinical managers and team leaders 3 yearly initial training then updates via e- 3 yearly initial training, Update by e- Infection Control Statutory - The Health Act 2006 (revised 2008), Code of Practice for the Prevention CQC Outcome 8, focuses on cleanliness and infection control and and Control of Healthcare Associated requires the Trust to comply with the requirements of the Code of Infections, HSCA reg 12, Standard 2: Practice for health and adult social care on the prevention and Competent & Capable Workforce control of infections". Criterion 8: Hand Hygiene Training & Risks include: Illness or death to patients, staff or visitors. Trust NHSLA Standard 4: Clinical Care reputation loss. Litigation Criterion 9: Infection Control, NHSLA TNA Minimum Data Infection Control - Clinical Staff Inpatient Doctors, Nursing & Support Staff, AHP's require annually. Psychologists, Pharmacists, CARAT workers, Community staff & Social Workers 3 yearly. Yearly or 3 yearly, workbook, e- Infection Control - Non Clinical staff Maintenance and Estates Staff, Domestic Staff Yearly, workbook, e- Safe Load Handling - Theory and Practice Admin, clerical, & corporate services staff, plus clinical staff who do not assist patients/clients with their movement i.e. Adult Mental Health Inpatients & Community these are low risk groups. Porters, Maintenance, Facilities & Estates workers these are high risk groups. Low risk staff groups - 3 Yearly High Risk Staff groups- Yearly 2

Safe Handling Statutory - Manual Handling Regulations 1992, NHSLA Standard 2 Competent & Capable Workforce - Criterion 9: Moving & Handling Training, TNA Minimum Data CQC Outcome 10 focuses on the Safety & Suitability of premises and requires the Trust to make sure that people who use services and people how work in or visit the premises are "in safe, accessible surroundings that promote their well-being, are protected against the risk of unsafe or unsuitable premises, and are compliant with any legal requirements".cqc Outcome 11 focuses on safety, availability and suitability of equipment and requires the Trust to ensure people "are not at risk of harm from unsafe or unsuitable equipment" Risks include: HASWA breached. HSE Improvement notice. Risk to Health. Sickness absence. Possible litigation and compensation claims. Safe Load Handling - Theory & Practice plus Patients Low Risk Safe Handling - Theory & Practice plus High Risk Patients All DNLD Community Nurses & Healthcare Support Workers, All Older Adults Community Nurses and HCSWs, All Community AHPs & AHP Assistants working in above inpatient settings All Older People s In patient Mental Health Nurses & Healthcare Support Workers Specialist Services Community Nursing Teams All AHPs & AHP Assistants working in above inpatient settings 2 Yearly Yearly Safe Handling - Train the Trainer 3 Day Course Nominated persons On appointment Safe Handling - Update for Key trainers Nominated persons Yearly 3

Topic Reference Mandatory Training Summary of Requirements - September 2013 Rationale - CQC Outcomes & Risk AED & Airway Management Qualified Nurses & Doctors - Inpatients. 3 Yearly Resuscitation Dual Diagnosis Food Safety Information Governance MAPA Resuscitation Council Guidelines, NHSLA Standard 4 Clinical Care - Criterion 9: Resuscitation, NHSLA TNA Minimum Data CQC Outcome 4 focuses on the care and welfare of people who use services and that "staff will quickly recognise when a person who uses services becomes seriously ill... and requires treatments and immediately responds to their needs" Resuscitation Council (UK) says all Trusts must provide at least annual BLS training to all clinical staff with a duty to respond. Risks includes: Potential loss of life, reputation, litigation. CQC Outcome 16 focuses on assessing and monitoring the quality NHSLA Standard 4 Clinical Care - Criterion 3: Management of Service Users of service provision and requires the Trust to "identify, monitor and with a Dual Diagnosis of Mental Health manage the risks to people who use, work in or visit the service" Problems & Substance Misuse, NHSLA and "improve the service by from adverse events, TNA Minimum Data incidents, errors and near misses" Risks include: Harm or death to patients or general public. Homicide. Litigation. Poor clinical Legislative Requirement - Food Safety Act 1990 HSCA Reg 20, NHSLA Standard 4 Clinical Care - Criterion 4: Health Record Keeping Standards Health & Safety at Work Act, HSCA reg 23, Criterion 9: Violence & Aggression, NHSLA Standard 4 Clinical Care - Criterion 1 Rapid Tranquillisation, NHSLA TNA Minimum Data CQC Outcome 5 focuses on meeting nutritional needs and requires the Trust to make sure that "the food and drink they provide supoprts health" and specifically that it is "handled stored, prepared and delviered in a way that meets the requirements of the Food Safety act 1990." Risks include: Food poisoning of staff or patients. Financial penalties CQC Outcome 21 focuses on records and requires the Trust to "manage risk through effective procedures about records to ensure that " people who use services can be confident that their personal records for their care, treatment and support are properly managed". Risks include: Reputational. Breach of duty of care. Breach of DPA. Potential financial penalties CQC Outcome 7 focuses on safeguarding people who use services from abuse and requires the Trust to protect others from the negative effect of any behaviour by people who use services. CQC Outcome 14, requires the organisation to ensure staff are properly trained and specifically that there are "clear procedures followed in practice, monitored and reviewed, that are implemented when staff are subject to violence, harassment or bullying by other staff or people who use services. Risks include: HASWA breached. HSE Improvement notice. personal injury.. Sickness absence. Possible litigation. Patient death. Staff injury/absence/death. Corporate manslaughter. Poor clinical practice. Anaphylaxis/Basic Life Support Do Not Attempt Resuscitation Dual Diagnosis Food Safety in Catering Level 2 Award Food Safety General Awareness Introduction to Information Governance Information Governance - The Beginners Guide DMI - 5 Day Foundation Violence & Aggression (Initial) DMI - 2 Day Foundation Violence & Aggression (Update) DMI - 2 Day Specialist Violence & Aggression (Initial) DMI - 1 Day Specialist Violence & Aggression (Update) All clinical staff working in an inpatients setting Once (Pscyhologists) require annually. Community staff require face to Yearly (Inpatient staff) or 3 face training 3 yearly with workbook in intervening yearly (Community Staff) years. Psychologists to complete face to face training on commencement - once only. Workbooks available for CARAT's, Doctors and Trainee Psychologists plus as supplementary resource for Specialist Community Teams. Anaphlaxis training required annually for all qualfiied nurses and will be included in medicines management training. Workbook for Anaphylaxis can be completed in alternate years. All Doctors. Qualified Nurses working in Older Peoples Services Community Specialist Nursing Teams Specialist School Nurses Senior Managers of Inpatient Services All Doctors, Nurses, Social Workers, Healthcare Support Workers and AHP s working in Forensic Mental Health, Adult and Older Peoples Mental Health, DNLD and Specialist Services Community & In-patient (excluding Substance, workbook, e-, Workbook. Misuse teams and Inclusion Services Catering, Ward Housekeepers, Porters, AHP s with 3 Yearly Face to Face specific food training roles, clinical staff working on Kinver, LSU, and Norton Inpatient staff who do not fall into the above category and AHPs/AHP Assistants All employees who have access to personal information All employees who do NOT have access to personal information. Catering, Housekeeping (Except ward housekeepers), Portering, Maintenance & Estates Inpatient Nurses, Forensic Mental Health Services, Mental Health including Older Peoples Services, Inpatient Healthcare Support Workers, AHPs & AHP Assistants Inpatient Nurses, Forensic Mental Health Services, Mental Health including Older Peoples Services, Inpatient Healthcare Support Workers, AHPs & AHP Assistants Inpatient Nurses, Inpatient Healthcare Support Workers, AHPs, AHP Assistants working in Kinver, Birmingham Tier 4 Service, Oak House, Castle Lodge, West Bank, Friary Day Centre, Tamworth Link, Kingsley Day Services and Community Staff in Child and Adolescent Mental Health Services 3 Yearly Face to Face or Workbook Once only Yearly Once only Inpatient Nurses, Inpatient Healthcare Support Yearly Workers, AHPs, AHP Assistants working in Kinver, Birmingham Tier 4 Service, Oak House, Castle Lodge, West Bank, Friary Day Centre, Tamworth Link, Kingsley Day Services and Community Staff in Child and Adolescent Mental Health Services E- E- 4

Mental Capacity Act & Advance Directives Mental Capacity Act 2005, HSCA reg 17, HSCA Reg 13 CQC Outcome 2 focuses on consent to care and treatment and explicitly requires the Trust to ensure that "staff understand the circumstances in which written consent must be taken, the way in which written consent must be documented, what to do when the wishes of the person who uses the service conflict with their care, welfare and safety needs or with those acting on their behalf" CQC Outcome 9 focuses on the management of medicines and requires staff to understand "the arrangements for requesting a second opinion in relation to medicines for people detained under the Mental Health Act". Risks include: Inappropriate treatment of patients, Litigation. Reputation. Mental Capacity Act & Advance Directives All Community Nurses All Nurses working in an inpatient setting All Psychologists All Doctors All Allied Health Professionals. Mental Health Act Mental Health Act 1983, HSCA reg 17, HSCA Reg 13 CQC Outcome 2 focuses on consent to care and treatment and explicitly requires the Trust to ensure that "staff understand the circumstances in which written consent must be taken, the way in which written consent must be documented, what to do when the wishes of the person who uses the service conflict with their care, welfare and safety needs or with those acting on their behalf" CQC Outcome 9 focuses on the management of medicines and requires staff to understand "the arrangements for giving medicines covertly where this is needed in accordance with the Mental Capacity Act". Risks include: Inappropriate detention or treatment of patients. Public safety risk. Patient safety risk. Mental Health Act All Community Nurses All Nurses working in an inpatient setting All Psychologists All Doctors All Allied Health Professionals * In Children s Services required only for staff working within CAMHS. Medicines Management Induction CQC Outcome 9 focuses on the management of medicines, and requires the Trust to ensure that we provide personalised care HSCA Regulation 13, NHSLA Standard 4 through effective use of medicines, manage risk through effective Clinical Care - Criterion 6: Medicines procedures about medicines handling, and specifically that "staff Management, NHSLA TNA Minimum Data handling medicines have the competency and skills needed", Risks include: Illness or death of patients through drugs errors. Litigation. Lost of Trust and Professional reputation. HSCA Reg 23, NHSLA Standard 2 Competent & Capable Workforce - Criterion 1: Corporate Induction, Criterion 2: Local Induction of Permanent Staff & Criterion 3: Local Induction of Temporary Staff, TNA Minimum Data CQC Outcome 14 focuses on supporting workers and requires the Trust to ensure that people who use services receive care treatment and support from staff who are competent to carry out their roles. Specifically that "all staff receive a comprehensive induction that takes account of recognised standards in the sector and is relevant to the workplace and their role". Risk include:higher staff turnover. Poor practice. Poor safety. Loss of reputation Medicines Management All doctors 3 yearly. All Community Nurses (ex Childrens) All Nurses working in an inpatient setting (ex Childrens) * In Children s Services required only for staff working within CAMHS Local Induction Programme All new employees Within 1 week of commencing employment Trust Corporate Induction for New Employees All new employees Within 12 weeks of commencing employment Trust Health & safety Induction for New employees All new employees Within 12 weeks of commencing employment., e-, e- Safeguarding Vulnerable Adults No Secrets' DoH 2000, HSCA Reg 11, Criterion 3: Safeguarding Adults, NHSLA Minimum Data CQC Outcome 7 - focuses on safeguarding people who use services from abuse and requires the Trust to "ensure that Government and local guidance about safeguarding people from abuse is accessible to all staff and put into practice." In particular the Trust needs to minimise the risk and likelihood of abuse occurring. Risks Include: Harm, injury or death to a patient. Trust reputation. Professional Reputation and dismissal Safeguarding Vulnerable Adults All Community Nurses and Healthcare Support Workers, All Nurses and Healthcare Support Workers in an inpatient setting, All Doctors, All Psychologists, All AHPs, A&C Staff working in clinical areas 3 yearly 5

Essential Professional Development - Clinical Skills NHSLA Standard 2 Competent & Capable Workforce Criterion 4: Clinical Supervision, NHSLA TNA Minimum Data Criterion 3: Safeguarding Adults CQC Outcome 14 focuses on supporting workers and requires the Trust to ensure that people who use services receive care treatment and support from staff who are competent to carry out their roles. Specifically that, " supervisory or support arranegments are in place, monitored and reveiwed, for all staff involved in delviering care, treatment and support" and "a support structure is in place for supervision which includes one-one sessions or group meetings" Risks include: Poor governacne & clincial pracice CQC Outcome 7 - focuses on safeguarding people who use services from abuse and requires the Trust to "ensure that Government and local guidance about safeguarding people from abuse is accessible to all staff and put into practice." In particular the Trust needs to minimise the risk and likelihood of abuse occurring. Risks Include: Harm, injury or death to a patient. Trust reputation. Professional Reputation and dismissal Clinical Supervision for Supervisors Clinical staff acting as clinical supervisors (excludes psychologists) Understanding Sexual Abuse Nurses & Healthcare Support Workers Inpatient & Community CARATS Workers AHPs & AHP Assistants Inpatient & Community Psychologists Doctors Criterion 3: Safeguarding Adults & Criterion 9: Violence & Aggression CQC Outcome 7 focuses on safeguarding people who use services from abuse and requires the Trust to protect others from the negative effect of any behaviour by people who use services. CQC Outcome 14, requires the organisation to ensure staff are properly trained and specifically that there are "clear procedures followed in practice, monitored and reviewed, that are implemented when staff are subject to violence, harassment or bullying by other staff or people who use services. Risks include: HASWA breached. HSE Improvement notice. personal injury.. Sickness absence. Possible litigation. Patient death. Staff injury/absence/death. Corporate manslaughter. Poor clinical practice. MAPA - Challenging Behaviour for Older People's Services All Nurses and Healthcare Support Workers Yearly working in Older Peoples Services. NHS Constitution, Trust Policy CQC Outcome 14 focuses on supporting workers and requires the Trust to ensure that staff are properly trained, supervised and appraised, specifically that " the development of staff is supported through a regular system of appraisal that promotes their professional development and reflects any relevant regulatory and/or professional requirements. Risks include: Risks of incompetence leading to poor performance and practice. Risk to quality of service provision. Low morale, high staff turnover. Appraisal (Personal Development Review) Managers, Supervisors and Team Leaders, E- ACAS Code of Practice, Trust Policy Criterion 8: Harassment & Bullying, NHSLA TNA Minimum Data CQC Outcome 14 focuses on supporting workers and to esnure "there is an open culture in the service which allows staff to feel supported to rasie concerns without any fear of recrimination" Risks include: Poor performance and practice. Risk to quality of service provision. Unfair dismissal claims. Compensation + Financial penalties CQC Outcome 14 focuses on supporting workers and includes ensuring that "staff are supported to do their work in a safe working environment where risk of violence, harassment and bullying are assessed and minimised" Risks include: Poor performance and practice. Risk to quality of service provision. Unfair dismissal claims. Compensation + Financial penalties Grievance and Disputes Managers, Supervisors and Team Leaders Harassment and Bullying Managers, Supervisors and Team Leaders, E-, E- Essential Professional Development - Human Resource Management ACAS Code of Practice CQC Outcome 12 focuses on requirements relating to workers and includes ensuring that "there are clear procedures followed in practice when staff behave outside the polices and procedures of the service or professional codes of conduct or practice that apply to them" Risks include: Poor performance and practice. Risk to quality of service provision. Unfair dismissal claims. Compensation + Financial penalties Handling Discipline at Work/Managing Performance Supporting Staff Managers, Supervisors and Team Leaders, E- 6

Criterion 2: Sickness Absence CQC Outcome 12 focuses on requirements relating to workers and includes ensuring that "there are clear procedures followed in practice when staff are not well enough to work" Risks include: Poor performance and practice. Risk to quality of service provision. Unfair dismissal claims. Compensation + Financial penalties Managing Attendance Managers, Supervisors and Team Leaders, E- HSCA reg 21, NHS Employment Check Standards Public Interest Disclosure Act 1998 NHS Counter Fraud & Security Management Service. CQC Outcome 12 focuses on requirements relating to workers and requires the Trust to esnure that "staff are recruited following effectvie recruitment and selection procedure that complies with legislation about employment, eqialities and human rights" Risks include: Poor performance and practice. Risk to quality of service provision. Unfair dismissal claims. Compensation + Financial penalties CQC Outcome 14 focuses on supporting workers and to esnure "there is an open culture in the service which allows staff to feel supported to rasie concerns without any fear of recrimination" Risks include: Loss of reputation. Financial loss. Criminal proceedings. Recruitment and Selection and Interviewing Skills Managers, Supervisors and Team Leaders Whistleblowing and Fraud Managers, Supervisors and Team Leaders, E-, E- 7