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)
Regulation 19 adds the fit-and-proper-persons duties that this policy operationalises:
have the qualifications, competence, skills and experience which are necessary for the work to be performed by them, and (Reg 19(1)(b) (qualifications + competence))
Regulation 12 adds the safe-care duty on competence that this policy supports:
ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely, (Reg 12(2)(c) (staff competence))
The full text is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/18, https://www.legislation.gov.uk/uksi/2014/2936/regulation/19 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/12. 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. Reg 18 does not set a number-of-hours training requirement; it requires that training and competence are sufficient for the role and the risks involved, which is why a certificate alone is not the same as competence in practice.
3. Purpose
The purpose of this policy is to make sure that all people working in [Service Name] have the training, competence, skills, support and supervision needed to carry out their role safely.
Training is not complete simply because a certificate has been issued. The service must be satisfied that staff understand the training and can apply it in practice.
This policy supports Regulation 18 staffing, Regulation 12 safe care and treatment, Regulation 17 good governance and Regulation 19 fit and proper persons employed.
4. Policy warning
No person must work unsupervised in a task they are not competent to carry out.
Mandatory training that is overdue, incomplete or not understood must be treated as a safety and governance concern, not only an HR issue.
Where a person lacks competence for a task, the Registered Manager must restrict the task, provide support, arrange training or take other protective action.
5. Scope
This policy applies to:
- permanent staff
- temporary staff
- bank staff
- agency staff
- volunteers
- contractors
- students and trainees
- registered professionals
- managers and senior staff
It applies to induction, mandatory training, role-specific training, refresher training, competency assessment, supervision, professional development and training records.
6. Principles
The service will make sure that:
- training requirements are based on role, risk and service type
- staff complete induction before working unsupervised
- competence is assessed in practice where the task creates risk
- training is refreshed at appropriate intervals
- training gaps are monitored and acted on
- staff receive supervision and appraisal
- professional staff are supported to meet regulator requirements
- training records are accurate and available for inspection
- agency and temporary staff receive local induction before working
7. Responsibilities
The Registered Manager is responsible for defining training requirements, monitoring compliance, acting on gaps and ensuring that staff are competent.
Managers and supervisors are responsible for supporting staff, assessing competence, identifying learning needs and escalating concerns.
Staff are responsible for completing training, applying it in practice, asking for support when needed and not undertaking tasks outside their competence.
The provider or Nominated Individual is responsible for ensuring that the service has enough resources, systems and oversight to maintain staff competence.
8. Training matrix
The service must maintain a training matrix.
The matrix must include:
- staff name
- role
- start date
- required training
- completion date
- expiry or refresher date
- evidence of completion
- competency assessment where required
- overdue status
- manager responsible
- role-specific training needs
The training matrix must be reviewed at least monthly.
9. Induction
All staff must complete an induction appropriate to their role before working unsupervised.
Induction must include, where relevant:
- service values and expectations
- safeguarding adults
- safeguarding children where relevant
- whistleblowing and raising concerns
- incident reporting
- complaints
- duty of candour
- infection prevention and control
- medicines awareness or medicines competence
- moving and handling
- fire safety
- health and safety
- emergency procedures
- confidentiality and data protection
- consent
- Mental Capacity Act and DoLS or Court of Protection where relevant
- equality, diversity and dignity
- person-centred care
- record keeping
- lone working where relevant
- service-specific risks
- escalation and on-call arrangements
- role boundaries
The induction must be recorded and signed off by a competent person.
10. Mandatory training
The service will define mandatory training by role.
Mandatory training may include:
- safeguarding adults
- safeguarding children
- basic life support or first aid appropriate to role
- fire safety
- infection prevention and control
- moving and handling
- medicines
- Mental Capacity Act
- Deprivation of Liberty Safeguards or Court of Protection route where relevant
- duty of candour
- information governance and data protection
- equality and diversity
- health and safety
- lone working
- food hygiene where relevant
- learning disability and autism training appropriate to role
- service-specific clinical or care training
Training meeting the Oliver McGowan Code of Practice standards on learning disability and autism is a statutory requirement for all CQC-registered providers, and the level required must be appropriate to the role.
The training matrix must show which training applies to each role.
11. Role-specific training
Role-specific training must be identified before the person works independently.
Examples include:
- medicines administration
- controlled drugs
- wound care
- phlebotomy
- vaccination
- diagnostic equipment
- medical devices
- clinical observations
- moving and handling equipment
- restraint or restrictive intervention
- positive behaviour support
- emergency equipment
- driving or patient transport
- safeguarding lead responsibilities
- chaperone duties
- infection control lead role
- audit lead role
- registered professional responsibilities
The person must not perform role-specific tasks until competence has been confirmed.
12. Competency assessment
Competency assessment is required where training alone is not enough to demonstrate safe practice.
This includes tasks that may affect:
- safety
- medicines
- clinical care
- infection control
- moving and handling
- emergency response
- safeguarding
- restraint
- use of equipment
- driving or transport
- lone working
- care planning or risk assessment
Competence may be assessed through:
- observation of practice
- supervised practice
- questioning
- scenario discussion
- written assessment
- reflective discussion
- review of records
- sign-off by a competent assessor
The competency record must state what was assessed, who assessed it, date, outcome and any restrictions or further training required.
13. Refresher training
Training must be refreshed at intervals set by the service, legal requirement, professional guidance, commissioner requirement or risk assessment.
The Registered Manager must decide refresher frequency by considering:
- level of risk
- role
- frequency of task
- incident history
- changes in guidance
- staff confidence
- competency concerns
- professional requirements
Where training expires, the manager must decide whether the person can continue the task safely, whether supervision is required, or whether the task must be restricted.
14. Overdue training
Overdue training must be reviewed at least monthly.
The manager must consider:
- risk linked to the overdue training
- whether the person can continue in full duties
- temporary restrictions
- supervision required
- booked training date
- reason for delay
- repeated non-compliance
- escalation to the provider where needed
High-risk training gaps must be acted on immediately.
15. Supervision and appraisal link
Training and competency must be reviewed through supervision and appraisal.
Supervision must consider:
- confidence in role
- competence in practice
- training gaps
- incidents or complaints involving the person
- safeguarding knowledge
- record keeping
- support needs
- professional development
- role changes
- health or wellbeing issues affecting practice
Appraisal must review the person's performance, development and future training needs.
16. Professional registration and CPD
Where the person is registered with a professional regulator, the service must support them to meet continuing professional development and revalidation requirements.
The service must not prevent, limit or obstruct a registered professional from meeting regulator requirements.
Professional staff must tell the Registered Manager if their registration is restricted, suspended, lapsed or under investigation.
The Registered Manager must act where professional-registration concerns may affect safe practice.
17. Agency, bank and temporary staff
Agency, bank and temporary staff must not be assumed competent because they have been supplied by another organisation.
Before they work, the service must confirm:
- identity
- role
- relevant training
- competence for the task
- professional registration where required
- local induction
- restrictions or limitations
- supervision arrangements
- escalation route
For repeated or long-term agency use, training and competence assurance must be refreshed.
18. Learning disability and autism training
Staff must receive training in how to interact appropriately with people with a learning disability and autistic people at a level appropriate to their role.
Where the service supports people with a learning disability or autistic people, role-specific training and supervision must reflect the person's communication, sensory, behavioural and support needs.
Competence must be maintained through supervision, reflective practice and review of incidents or concerns.
19. New or changed services
Training needs must be reviewed when:
- a new service starts
- the service accepts a person with new or complex needs
- new equipment is introduced
- medicines arrangements change
- a new procedure is introduced
- guidance changes
- there is an incident, complaint or safeguarding concern
- CQC or another body identifies a gap
- staff move into a new role
The service must not start a higher-risk activity until staff competence is in place.
20. Training evidence
Training records must include:
- course title
- provider
- date completed
- expiry date where relevant
- certificate or evidence
- assessment outcome where relevant
- competency sign-off where relevant
- restrictions or further learning required
- manager review
Certificates alone may not be enough for high-risk tasks. The service must be able to show competence in practice.
21. Audit and governance
The Registered Manager must audit training and competency records at least quarterly.
The audit must check:
- mandatory training compliance
- overdue training
- role-specific training
- competency sign-offs
- induction completion
- supervision link
- professional-registration requirements
- agency staff assurance
- repeated gaps
- actions taken
Training gaps that affect safety must be added to the action plan or risk register.
The provider or Nominated Individual must review training compliance at least quarterly.
22. Failure to complete training
Where a staff member fails to complete required training without good reason, the manager must take action.
This may include:
- reminder and support
- protected time to complete training
- supervision
- restriction from specific duties
- capability process
- conduct process
- removal from role where safety requires it
The response must be proportionate to the risk.
23. Related policies in this pack
This policy should be read with:
- Staffing Policy
- Safe Recruitment Policy
- Supervision and Appraisal Policy
- Safe Care and Treatment Policy
- Good Governance Policy
- Incident Reporting, Investigation and Learning Policy
- Risk Management and Risk Register Policy
- Medicines Policy
- Safeguarding Policy
- Moving and Handling Policy
- Infection Prevention and Control Policy
- Record Keeping Policy
- Staff Conduct and Disciplinary Policy
24. Review
This policy will be reviewed annually, or sooner following a CQC finding, serious incident, safeguarding concern, repeated training gap, change in law or guidance, new service type, or change in staff roles.
25. 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.
- CQC Regulation 18: Staffing
- CQC Regulation 12: Safe care and treatment
- CQC Regulation 19: Fit and proper persons employed
- Skills for Care / Skills for Health workforce development guidance
- Learning disability and autism training requirements under the Health and Care Act 2022 and current Oliver McGowan / DHSC / CQC guidance
- Professional regulator CPD and revalidation guidance (for example NMC, GMC, GDC, HCPC)
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/18)
26. 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.
27. Document control
| Version | Date | Author | Changes |
|---|---|---|---|
| v1 | 2026-06-10 | Verivius (sample) | Initial sample template, conformed to the Verivius policy standard. |
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.