Sample policy · Reg 18 staffing

Staffing policy template

Statutory anchor: Regulation 18 (staffing), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 19 (fit and proper persons employed) and Regulation 17 (good governance). · primary source

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The PDF version of this template is the same content, formatted for adaptation in your document control system. The disclaimer above is repeated on the PDF cover.

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Verivius pack version v1, 2026-06-10

1. What the regulation says

Sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed in order to meet the requirements of this Part. (Reg 18(1): the headline duty)

receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform. (Reg 18(2)(a): support, training, supervision and appraisal)

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/18. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

You have to deploy enough suitably qualified, competent, skilled and experienced staff to meet Part 3. Staff have to receive appropriate support, training, professional development, supervision and appraisal. Where staff are health or social-care registered professionals, they have to be enabled to give their regulator evidence of meeting professional standards.

3. Scope

This policy applies to all staffing decisions across : workforce planning, recruitment, induction, supervision, appraisal, training, professional development, continuing professional competence, and the support a member of staff receives day to day. It covers every clinical and non-clinical role, employed and contracted staff, agency and locum cover, and external parties working alongside the team.

(Tenant updates the angle-bracket placeholder.)

4. Roles and responsibilities

(Tenant updates the named role-holders.)

5. Procedure

The Reg 18 procedure operationalises the staffing duty across the workforce lifecycle.

  1. Workforce plan. The Registered Manager maintains a workforce plan: the role-and-headcount required to deliver the regulated activity safely at each location, by role, by shift pattern. The plan is reviewed quarterly and on any change of service shape.
  2. Sufficient numbers. Daily staffing levels are checked against the workforce plan. Where actual is below planned, the gap is filled (own-staff cover, bank, agency) or service activity is reduced to a safe level. A pattern of repeated gaps triggers a workforce-plan review.
  3. Recruitment. Recruitment follows the Reg 19 fit-and-proper-persons-employed process (Schedule 3 information per the Fit and Proper Persons Employed Policy). Sufficiency includes the right skill mix, not just headcount.
  4. Induction. New staff complete induction before unsupervised work begins. Induction includes role-specific training, Reg 18 mandatory training topics, the platform's tour, the provider's policies, and a buddy or mentor arrangement for the first weeks.
  5. Supervision. Supervision runs per the Supervision Policy. Cadence per role and per session type (one-to-one, group, peer, clinical, reflective practice). The platform's supervision register holds the record of every session.
  6. Appraisal. Annual appraisal for every member of staff. Appraisal covers the year's performance against role expectations, training completion, professional development plan, any concerns surfaced, the year ahead's objectives. The appraisal record sits against the person record.
  7. Continuing professional development. Each member of staff has a personal CPD plan aligned to the role and any professional-registration requirements. The CPD plan is reviewed at appraisal.
  8. Professional registration. Where the role requires professional registration (NMC, GMC, HCPC, GDC, GPhC, Social Work England, etc.), the registration is verified against the live register at appointment, the renewal date is on the assurance calendar, and lapses are escalated immediately. Lapsed registration means the role cannot be performed.
  9. Capability and conduct concerns. Where a capability or conduct concern surfaces (in supervision, appraisal, incident review, complaint, peer report), the concern is recorded and the appropriate process runs: capability process for skills-and-competence concerns; conduct process for behaviour or safeguarding concerns. Both processes preserve the staff member's rights and the service users' safety.
  10. Workforce review at governance meeting. Aggregate workforce metrics (vacancy rate, sickness rate, training-currency rate, supervision-current rate, appraisal-current rate, professional-registration-currency rate) are reviewed monthly at the clinical governance meeting.

6. Training and the staff training plan

The Service holds a staff training plan that identifies the training every member of staff needs to deliver safe, effective and person-centred care, aligned to Regulation 18, to the Care Certificate standards for staff new to care, and to the service-user needs set out in the Service's statement of purpose. The plan covers:

Induction and mandatory training.

Role-specific training.

Specialist training.

Training providers.

Refresher training.

Support for overseas workers.

The training plan and the training matrix are held in the tenant's training register; currency is surfaced on the assurance calendar and reviewed monthly.

(Tenant completes the named training providers, the service-user bands, and the per-topic refresher schedule to fit its own service.)

7. Audit

Compliance with this policy is monitored by the HR Lead and the Registered Manager jointly:

Audit findings recorded in the tenant's audit register; actions logged in the improvement-actions register.

8. Record-keeping

Staffing records (workforce plan, recruitment records, induction records, supervision records, appraisal records, training matrix entries, CPD plans, professional-registration verifications, capability and conduct records) are held for the duration of the staff member's tenure plus a minimum of 6 years after the end of tenure under the Limitation Act 1980, aligned to the standard limitation period.

Verivius preserves the per-record audit trail indefinitely while the workspace is active.

9. Related policies in this pack

10. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

11. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

12. Document control

Version Date Author Changes
v1 2026-05-19 Verivius (sample) Initial sample template.
v1.1 2026-06-01 Verivius (sample) Filled out Sections 3 to 8 with concrete content. Section 4 names HR Lead, Clinical Lead, line managers. Section 5 expanded to a 10-step procedure covering workforce plan, sufficient numbers, recruitment, induction, supervision, appraisal, CPD, professional registration, capability and conduct concerns, workforce review at governance meeting. Section 6 names training categories. Section 7 names the five audit cadences. Section 8 references the Limitation Act 1980 retention period.
v1.2 2026-06-05 Verivius (sample) Rebuilt Section 6 into a staff training plan meeting CQC's training-plan checklist: induction mapped to the Care Certificate, mandatory training matched to business and service-user needs, role-specific training including managers, specialist training by service-user band (dementia, sensory, mental health, learning disability and autism incl. Oliver McGowan), named training providers, per-topic refresher cadence, and support for overseas workers. Updated stale related-policy slugs.
v1.3 2026-06-10 Verivius (sample) Re-conformed to the current Verivius policy standard, preserving the original content. Current disclaimer and header block applied; verbatim Reg 18 quotes carry cite labels; plain-English summary aligned to the guidance manifest; engaged Regulation 19 and Regulation 17 named in the anchor; added Sources and further reading and When to seek further advice; renumbered Document control to Section 12.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

Staffing is the regulation most of the others quietly depend on. A medicines error, a missed sign of deterioration, or a restraint that a confident team would have talked down usually traces back to the wrong number of people, or the wrong skills, on one particular shift. A person feels short staffing directly, in the call bell that takes longer to answer and the handover done at a run, long before it shows up in any audit. Specialist training matched to the people actually supported, learning disability and autism or dementia care for example, is the difference between care that is merely delivered and care that is understood. What carries weight as evidence is not the workforce plan in the folder but the record of the Tuesday night that ran two people short: who covered, or what activity was safely stood down. That same trail is what lets a registered manager catch a pattern of repeated gaps before it becomes a harm rather than after.

  1. The staff actually on shift match the workforce plan for that location and shift pattern, not just a workforce plan that exists on paper. Where actual falls below planned, the gap is filled (own-staff cover, bank, agency) or service activity is reduced to a safe level, and a pattern of repeated gaps triggers a review.

    Strong evidence: The weekly staffing-versus-plan check (actual versus planned headcount per shift) with gaps logged and addressed, held against the workforce plan reviewed quarterly and on any change of service shape.

    Weak evidence: A workforce plan reviewed on time but never reconciled against who was actually on shift, so a run of short-staffed nights leaves no trace. Gaps waved away as 'we always manage', with no record of bank or agency cover secured or of activity being safely reduced, and no plan review triggered when the same shift keeps coming up short.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 18(1)

  2. Professional registration was verified against the live register at appointment and the renewal date is actively tracked, not assumed current. The failure that matters is a person still working a role whose registration has lapsed, because lapsed registration means the role cannot be performed and care is being delivered by someone the register no longer covers.

    Strong evidence: The professional-registration verification against the live register (the Nursing and Midwifery Council (NMC), General Medical Council (GMC), Health and Care Professions Council (HCPC), General Dental Council (GDC), General Pharmaceutical Council (GPhC), Social Work England and similar) with the renewal date on the assurance calendar and lapses escalated immediately.

    Weak evidence: A certificate photocopied at interview and never rechecked, or a registration number held on file that was never confirmed against the live professional register. Renewal dates kept nowhere in particular, so a lapse only surfaces when someone happens to notice, by which point the person may already have worked a role their registration no longer covers.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  3. New staff complete induction and the mandatory training set before they start unsupervised work, not after they are already delivering care.

    Strong evidence: The induction record showing role-specific training, the mandatory training topics the service requires (Regulation 18 requires appropriate training but does not prescribe this list; safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards awareness, infection prevention and control, moving and handling, basic life support and the rest), the policies and a buddy or mentor arrangement, all completed before unsupervised work begins.

    Weak evidence: An induction checklist signed off weeks after the person began delivering care, or mandatory training booked 'to be finished during probation' while they already work unsupervised. Safeguarding or Mental Capacity Act awareness dated after the first shifts, or a buddy named on paper who was on leave that week.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  4. The training matrix is genuinely current for each role and topic, and specialist training matches the service-user bands the service actually supports, not a generic list. Below-threshold cells and missing specialist training (for example learning-disability and autism training) are the gap that matters, because the people named in the statement of purpose are the ones whose needs go unmet when the training is not there.

    Strong evidence: The monthly training-currency dashboard (matrix percentages by role and topic, below-threshold cells investigated) with refresher dates tracked on the assurance calendar.

    Weak evidence: A matrix that reads green because leavers were deleted and new starters were never added, so the percentage describes a workforce that no longer exists. A generic mandatory list with no specialist rows for the people the service actually supports: no learning-disability and autism training recorded for a service whose statement of purpose names autistic people, and below-threshold cells left with no note of why or what is being done about them.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  5. Supervision and appraisal are actually current against the stated cadence, not just a supervision policy that exists. The one to look for is the individual whose supervision has quietly slipped or whose appraisal is overdue, because that is the colleague carrying the work with nobody checking how they are holding up.

    Strong evidence: The quarterly supervision-currency audit (percentage of staff with current supervision per cadence against the workforce list) and the annual appraisal-completion figure, with the supervision register holding each session.

    Weak evidence: A supervision register whose last entry for several staff is months old, sitting beside a policy stating a cadence nobody is held to. Appraisals clustered at year-end to reach a percentage rather than spread across the year. The quiet, capable member of staff whose supervision has slipped with nobody following it up, and sessions recorded as a date and a signature with no trace of what was actually discussed or decided.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

Related

Last verified 20 July 2026

Audit this policy

Staffing and safer recruitment procedure checklist

A policy is the intent; the evidence is what a CQC inspector actually asks to see. This matching checklist turns the policy above into the records to keep, the audit to run, and the places small services most often fall short.

Open the Staffing and safer recruitment procedure checklist

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Last reviewed 10 June 2026