Sample policy · Reg 18

Training, Competency and Mandatory Training Policy

Statutory anchor: Regulation 18 (staffing), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 12 (safe care and treatment) and Regulation 19 (fit and proper persons employed). · primary source

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Verivius pack version v1.1, 2026-07-19

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:

It applies to induction, mandatory training, role-specific training, refresher training, competency assessment, supervision, professional development and training records.

5.1 Local arrangements before adoption

Before adoption, [Service Name] records:

The provider must reconcile the matrix against the current workforce and rota, not only employee files. Nobody should appear deployable for a task when their competence, training or professional authority is absent, expired or restricted.

6. Principles

The service will make sure that:

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. Operational training and competency workflow

Managers follow this sequence for every role and worker:

  1. Define the requirement: use the service risk assessment, job description, regulated activity, current law, professional guidance, equipment and people's needs to set role-specific learning and competence requirements.
  2. Check before deployment: verify identity, qualification, registration, prior learning and evidence, then record gaps and the level of supervision required. Do not accept a supplier or agency assurance without local checks proportionate to the task.
  3. Induct and train: provide local induction and the required learning before unsupervised work, with accessible teaching and protected time.
  4. Assess competence: observe or test the person in practice where the task carries risk. Record the activity assessed, assessor, standard, outcome, limitations and review date.
  5. Authorise or restrict: record which duties the person may perform independently, under supervision or not at all. Communicate restrictions to rota and operational leads.
  6. Monitor: maintain the live training matrix, review expiries and professional status, and use supervision, audit, feedback and incidents to identify new needs.
  7. Respond to a gap: protect people, restrict duties where needed, arrange support and reassessment, and escalate repeated or high-risk failures through staffing, HR, professional and governance routes.
  8. Reassess and improve: refresh learning after the set interval or a change, concern or extended absence, then check through practice evidence whether the learning improved safety and performance.

8.1 Training matrix

The service must maintain a training matrix.

The matrix must include:

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:

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:

CQC-registered providers must ensure staff receive learning disability and autism training appropriate to their role. The final Oliver McGowan code of practice sets the standards for that training. The Oliver McGowan Mandatory Training package is the government's preferred and recommended route, not the only permitted package. A provider using another route must be able to explain and evidence how it meets the legal requirement and the code.

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:

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:

Competence may be assessed through:

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:

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:

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:

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:

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:

The service must not start a higher-risk activity until staff competence is in place.

20. Training evidence

Training records must include:

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:

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:

The response must be proportionate to the risk.

23. Related policies in this pack

This policy should be read with:

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.

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.
v1.1 2026-07-19 Verivius (sample) Added local role and authorisation decisions, an end-to-end competence workflow and clarified the final Oliver McGowan code position.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider'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.

Training is the one policy where the paperwork can be complete and the practice still unsafe, because a certificate records attendance while harm happens at the hoist, at the medicines trolley or at the moment somebody stops breathing. The people most exposed are those who cannot correct a worker who is out of their depth: someone with a swallowing risk supported by staff who watched a video on safe eating and drinking but were never observed at a mealtime, or an autistic person met by a worker who has ticked a generic module and does not know their communication needs. Competence also decays quietly, so the risk grows in the months after a certificate is issued rather than on the day it expires, and it changes again with every agency shift, every new device and every person admitted with more complex needs. A live matrix reconciled against the rota is what turns training from a human resources record into a deployment control, because it lets a manager say who can safely do what today. Inspectors will ask to see it, but the reason to keep it accurate is that it decides who is standing next to the person when something goes wrong.

  1. Competence is demonstrated in practice for high-risk tasks, not inferred from a certificate on file. A certificate confirms attendance, not that the person can carry out the task safely for someone in their care, which is what observed, assessed competence shows.

    Strong evidence: The competency record stating what was assessed, the assessor, date, outcome and any restrictions, plus observation or supervised-practice records (sections 12 and 20; checklist: 'Observed or supervised practice is recorded where required').

    Weak evidence: A folder of e-learning certificates for medicines, moving and handling or use of a device, with no competency record naming what was observed, who assessed it, the outcome and any restrictions. Or a competency form marked "competent" for several staff by one assessor on one date, with no review date and nothing showing anyone was watched carrying out the actual task.

    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 12(2)(c)

  2. Staff are deployed only within their competence, so nobody is rostered for a task where their training, competence or professional registration is absent, expired or restricted. What protects the person receiving care is the rota reconciled against the matrix, not tidy employee files on their own.

    Strong evidence: The live training matrix reconciled against the current workforce and rota, with restrictions communicated to rota and operational leads (sections 5.1, 8 step 5 and 8.1; checklist: 'Rota or duty leads know about restricted tasks').

    Weak evidence: The matrix is tidy but nobody has ever laid it next to the rota, so a person whose medicines competence has expired or whose professional registration has lapsed is still rostered for the medicines round. Or a restriction is agreed in supervision and filed in the employee record while the person building the rota is never told, so the restriction exists only on paper.

    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) and reg 12(2)(c)

  3. Overdue mandatory training is treated as a safety and governance risk and acted on immediately for high-risk gaps, not carried as an HR backlog. What counts is the action taken on each overdue high-risk item, because that is the gap that reaches the person in care first.

    Strong evidence: The at-least-monthly overdue-training review, any duty restrictions or escalation, and safety-affecting gaps added to the action plan or risk register (sections 4, 14 and 21; checklist: 'Overdue training is escalated before it becomes a safety gap').

    Weak evidence: An overdue report produced and filed each month with the same high-risk names carried forward, and no note of what was restricted, booked or escalated in between. Or a single compliance percentage quoted at a team meeting that hides whether the gaps are basic life support and safeguarding rather than an equality and diversity refresher.

    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.

  4. New starters and agency, bank or temporary staff complete local induction before working unsupervised, not assumed competent because a supplier vouched for them. The checks that protect the person in care are the ones done before the first shift, not another organisation's word taken on trust.

    Strong evidence: Induction records signed off by a competent person, and the pre-work confirmation of identity, relevant training, competence and local induction for agency and temporary staff (sections 9 and 17; checklist: 'Agency, bank, contractor or locum staff receive local safety induction').

    Weak evidence: An agency profile or supplier compliance certificate accepted at face value, with no local record of identity checked, training verified or induction completed before the first shift. Or an induction checklist signed only by the new starter, with no sign-off by a competent person and no date showing it was finished before they worked unsupervised.

    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.

  5. Learning-disability and autism training (a Regulation 18 statutory training requirement) is in place at the level appropriate to each role, and where a package other than the Oliver McGowan route is used, the provider can evidence how it meets the code. What people with a learning disability and autistic people rely on is training matched to each role, not a single generic tick.

    Strong evidence: The training matrix showing learning-disability and autism training mapped to role (sections 10 and 18; checklist: 'Learning disability and autism training level is matched to role').

    Weak evidence: A single line in the matrix reading "Oliver McGowan, completed" against every member of staff at the same level, with nothing showing which level each role actually needed. Or an alternative or in-house package logged with a certificate alone, and no written explanation of how its content and delivery meet the code of practice and the statutory requirement.

    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.

  6. Training needs surfaced by incidents, complaints, safeguarding and audits feed back into the matrix and supervision, and the audit runs at the stated cadence and is reviewed at provider level. Training that keeps pace with what went wrong stops the same gap reaching the next person in care.

    Strong evidence: The at-least-quarterly training audit, training needs from incidents added to the matrix or action log, and the provider or Nominated Individual review of training compliance (sections 15, 19 and 21).

    Weak evidence: Incidents, complaints and safeguarding concerns closed with "staff reminded" or "staff to re-read the policy", and no matching entry in the training matrix, supervision notes or action log. Or a training audit that reports compliance percentages only, never revisits whether earlier actions were completed, and reaches the provider or Nominated Individual as a figure with no discussion recorded.

    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

Training, competency and mandatory training 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 Training, competency and mandatory training procedure checklist

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Last reviewed 19 July 2026