This plan gives you a systematic approach to staff training compliance. You'll implement:
Role-based training matrix defining requirements for every staff type
Current state audit showing exactly where your gaps are
Gap analysis with risk prioritization (statutory, professional, role-specific)
Master training tracker (your single source of truth for CQC)
Ongoing monitoring system (quarterly audits, maintenance schedule)
This is the kind of systematic workforce management that demonstrates strong governance to CQC, protects your practice from compliance gaps, and shows genuine HR leadership capability. Getting training right demonstrates you understand professional regulation, risk management, and continuous improvement.
Implementation timeframe: 6-8 weeks for full system implementation, with immediate risk mitigation in week 1-2
Why This Matters
For Your Practice
Patient safety: Competent staff provide safer care. Missing safeguarding training, infection control updates, or clinical competency assessments creates direct patient risk.
Regulatory compliance: Meet CQC Regulation 18 (Staffing) requirements and avoid enforcement action. CQC expects evidence that staff have "the qualifications, competence, skills and experience to do their job."
Professional protection: Protect regulated staff (GPs, nurses, pharmacists) from professional body sanctions. GMC revalidation, NMC revalidation, and GPhC CPD requirements are non-negotiable.
Reduced liability: Training records provide evidence in claims and complaints. Documentation that you provided appropriate training and supervision supports your defense against negligence allegations.
Staff retention and satisfaction: Clear development pathways and investment in training improves morale and reduces turnover. Staff want to learn and grow.
Operational efficiency: Proper training reduces errors, improves workflow, and prevents the chaos of last-minute compliance panics before CQC inspections.
For Your Professional Development
By leading this improvement, you'll demonstrate:
HR and workforce management expertise: Designing systematic training compliance frameworks aligned with regulatory requirements and professional body standards
Risk management capability: Identifying training gaps with patient safety and regulatory implications, prioritizing remediation based on risk
System design and project management: Creating training matrices, implementing tracking systems, establishing ongoing governance
Stakeholder engagement across professional groups: Working with GPs on revalidation, nurses on NMC requirements, admin staff on mandatory training, securing partner buy-in for budget
Continuous improvement leadership: Implementing sustainable monitoring systems that maintain compliance over time, not just one-off fixes
Add these achievements to your year-end evaluation: "Led implementation of comprehensive staff training system, achieving 95%+ compliance across all statutory training categories within 8 weeks, with sustainable quarterly monitoring framework maintaining compliance over [X] months."
Prerequisites and Preparation
What You Need Before Starting
Approvals: Partner sign-off (training has budget implications and operational impact), senior team agreement on training lead roles
Stakeholders: Identify your Training Leads for each staff group (GP lead for medical staff, Nurse Lead for clinical nursing staff, Practice Manager for admin/non-clinical, Pharmacist Lead if you have prescribing pharmacists)
Resources: Budget for external training courses (safeguarding face-to-face, fire marshal, specialized clinical training - practices commonly spend £3,000-8,000/year on staff training depending on size and service mix), staff time out of practice for training days, systems access (ESR/Trac, e-LFH, BlueStream, or other training platforms)
Current state: Gather all existing training records from wherever they currently live (SharePoint, paper folders, ESR, email confirmations, people's heads)
Estimated Time Investment
Total implementation: 6-8 weeks from kick-off to operational system with first audit complete
Your time commitment:
Weeks 1-4: 4-5 hours/week (planning, audit, matrix development, policy work)
Weeks 5-8: 2-3 hours/week (monitoring gap-filling, supporting leads, preparing presentation)
Ongoing: 2-3 hours/month (quarterly audits, tracker updates, reporting to partners)
Training Lead time: 2-3 hours/week during implementation, 1 hour/month ongoing
Staff time: Variable depending on training gaps (allow 2-4 days per person over first 3 months for catch-up)
Initial audit time: 6-8 hours total (gathering records, populating tracker)
The Implementation Plan
Phase 1: Kick-Off and the Training Matrix (Week 1-2)
Meeting 1: Initial Kick-Off
Attendees: Practice Manager, GP Partner, Training Leads for each staff group (GP Lead, Nurse Lead, Admin Lead), any pharmacist or advanced practitioners
Duration: 90 minutes
Agenda:
Present the problem and business case — Explain CQC Regulation 18 requirements (staff must have "qualifications, competence, skills and experience"), reference recent CQC inspection findings in your area if available, quantify current gaps if known (e.g., "3 staff have expired safeguarding training", "No systematic tracking of clinical competencies")
Review scope and objectives — Establish that you will create a role-based training matrix, audit current compliance, implement a master tracker, clear priority gaps within 8 weeks, establish ongoing quarterly monitoring, and present results to partners
Assign roles and responsibilities — Confirm Training Leads for each staff group (they own the requirements list for their group and monitor ongoing compliance), Practice Manager owns the master tracker and quarterly audits, Partners approve budget and policy
Set timeline and key milestones — Week 2: Training matrix complete; Week 4: Audit and gap analysis done; Week 6: Policy approved and tracker operational; Week 8: First compliance report to partners
Identify potential blockers — Budget constraints for external courses? Staff resistance to time out of practice? Missing records that can't be reconstructed? Unclear professional requirements for some roles?
Outputs:
Project charter with clear objectives: Create systematic training framework, achieve 95%+ statutory compliance, establish sustainable monitoring
RACI matrix: Training Leads (responsible for their staff group requirements), Practice Manager (accountable for overall system), Partners (consulted for budget and policy), All staff (informed and engaged)
Timeline with milestones and owners
Risk register: Budget overruns, staff time availability, missing historical records, professional body requirement complexity
Action: Build Your Training Matrix
This is the foundation of the entire system. You can't assess gaps until you know what's required.
The matrix structure:
Rows: Every role type in your practice (GP, Practice Nurse, HCA, Pharmacist, Prescriber, Practice Manager, Admin/Reception, Dispensary, IT/Systems, Cleaners/Facilities)
Columns: Training categories (see below)
Cells: Specific requirement and frequency (e.g., "Safeguarding Adults Level 2 - 3 yearly", "BLS - Annual")
Training categories to include:
1. Statutory and Mandatory Training (Everyone):
Fire safety awareness (typically annual, per local policy)
Health and safety awareness (typically annual)
Information governance and data security (annual, mandated by DSPT)
Infection prevention and control (annual for clinical staff; annual or 3-yearly for non-clinical staff depending on local policy and risk assessment)
Equality, diversity, and inclusion (typically 3-yearly)
Oliver McGowan Mandatory Training on Learning Disability and Autism (as required by Health and Care Act 2022)
Manual handling (typically 3-yearly, or annual if regular patient handling)
Prevent training (3-yearly; Counter-Terrorism and Security Act 2015 duty)
Safeguarding children (level depends on role—see Intercollegiate guidance)
Safeguarding adults (level depends on role—refer to Intercollegiate Document for Adult Safeguarding 2018 and local safeguarding partnership procedures)
2. Professional/Regulatory (Role-specific):
GPs: Annual CPD suitable for appraisal and revalidation, safeguarding Level 3, specialty-specific updates
Nurses: NMC revalidation (35 hours CPD, 20 participatory hours over 3 years), clinical competencies for procedures performed
Pharmacists: GPhC CPD (ongoing evidence of learning and reflection), prescribing updates if IP/SP
HCAs: Competency assessments for all delegated tasks (venepuncture, ECGs, chronic disease monitoring, etc.)
3. Role-Specific Clinical:
Chaperone training (for those who chaperone; requires Enhanced DBS check, especially for intimate examinations)
Phlebotomy competency (for those who take blood)
Spirometry competency (ARTP certification or national register accreditation preferred for those performing lung function tests)
Immunization and vaccination updates (for those administering vaccines)
Cervical screening (for those performing smears)
Minor surgery competencies (for assisting or performing)
Emergency drugs and anaphylaxis (clinical staff)
4. Role-Specific Non-Clinical:
Reception and telephone triage skills (for front desk)
Appointment system training (for admin staff)
Confidentiality and information sharing (for reception handling queries)
Complaints handling (for patient-facing staff)
Summarizing and coding (for note summarizers)
QOF and audit (for QOF leads)
Prescription processing (for dispensary/prescription handlers)
5. Induction (All new starters):
Practice orientation and tour
Clinical systems training (EMIS/SystmOne)
Emergency procedures and key locations
Key policies (safeguarding, IG, H&S, whistleblowing)
Role-specific buddy period
Using My Practice Manager Email Assistant:
The tool can help you identify requirements quickly. Email your request to mypm@automate.mypracticemanager.co.uk:
"Please create a draft list of the usual training requirements for staff in a GP practice. Please highlight specific role requirements for GPs, nurses, pharmacists and admin staff. Include statutory training, professional requirements, and role specific mandatory training."
You'll typically receive a comprehensive list within a few minutes. Then use that list to build your own matrix spreadsheet (rows = staff roles, columns = training categories). This gives you the content without trying to force the tool to create complex spreadsheet layouts.
Example follow-up queries for specific clarifications:
"What safeguarding level is required for GP receptionists?"
"What are NMC revalidation requirements for practice nurses?"
"What competency training do HCAs need for immunizations?"
"What is the Oliver McGowan training requirement for GP practice staff?"
"What Prevent training level do clinical staff need?"
Note on locums, temps, and ARRS staff: Include regular locums and attached staff (ARRS roles, community nurses who work from your practice) in your matrix. They need the same statutory training (fire, IG, safeguarding) and competency assessments for procedures they perform at your practice. Track them separately if they're not on your payroll, but CQC expects evidence they're competent and trained for work done at your site.
Outputs:
Complete training matrix showing every role and their specific requirements
Frequency/renewal schedule for each training item
Notes on "Statutory" vs "Professional" vs "Role-specific" categories for prioritization
Phase 2: Audit and Gap Analysis (Week 2-4)
Action: Conduct the Training Record Audit
This is your "current state assessment" - gather evidence of what training staff have actually completed.
Where to look for records:
NHS systems: ESR (Electronic Staff Record), Trac (training platform), e-LFH (e-Learning for Healthcare)
External providers: BlueStream, Fire Safety Matters, local safeguarding board certificates
Internal records: SharePoint training folders, personnel files, staff supervision notes
Individual staff: Ask staff to submit their own certificates and CPD records
Professional portfolios: GP revalidation portfolios, NMC online revalidation records, GPhC CPD records
Audit process:
Create the Master Training Tracker — This is your central spreadsheet (the "one source of truth")
Columns to include: Staff Name | Role | Training Item | Completion Date | Expiry Date | Status (Current/Expiring Soon/Expired/Not Done) | Evidence Location | Notes
Populate systematically — Work through one staff group at a time (all GPs first, then all nurses, then admin, etc.)
Mark missing records — If training can't be evidenced, mark as "Not Done" (even if staff claim they did it years ago - no certificate = not done for CQC purposes)
Calculate expiry dates — Use the frequency from your matrix (e.g., if fire safety completed 15 months ago and renewal is annual, mark as "Expired")
Using basic Excel formulas to help:
Status column: =IF(ExpiryDate<TODAY(),"Expired",IF(ExpiryDate<TODAY()+90,"Expiring Soon","Current"))
Conditional formatting: Red for expired, amber for expiring soon, green for current
Realistic timeframe: This takes longer than you think. Allow 6-8 hours total. Don't rush it—accuracy matters.
Action: Gap Analysis and Risk Assessment
Now compare your Matrix (what's required) against your Audit (what's been done).
Gap identification:
Mandatory gaps: Statutory and mandatory training that's missing or expired (safeguarding, fire, IG, H&S, IPC, Prevent, Oliver McGowan)
Professional gaps: CPD/revalidation shortfalls that could affect professional registration
Role-specific gaps: Competency assessments never done for tasks staff are currently performing
Induction gaps: New staff who never completed full induction
Risk prioritisation (use RAG rating):
RED (Immediate action required - Week 1-2):
Expired safeguarding for clinical staff (patient safety risk)
Missing Oliver McGowan training (statutory requirement under Health and Care Act 2022)
Missing Prevent training (statutory duty under Counter-Terrorism and Security Act 2015)
Missing competency assessments for clinical procedures currently being performed
GPs/Nurses with revalidation deadlines in next 3 months
Any "Never Done" training for tasks staff perform daily
AMBER (Action required - Week 3-6):
Expiring statutory training (within 90 days)
Professional CPD shortfalls with deadlines 3-12 months away
Role-specific training that enhances but isn't critical for current role
GREEN (Plan for next cycle):
Development training that improves capability but isn't mandatory
Refresher training not yet due
Outputs:
Master Training Tracker fully populated with current state
Gap analysis report showing compliance percentages by category (e.g., "Statutory training: 68% compliant, Professional: 82%, Role-specific: 55%")
Risk-prioritized action plan: RED items (20 training instances), AMBER items (35 instances), GREEN (ongoing)
Meeting 2: Gap Analysis Review
Attendees: Implementation team plus Training Leads
Duration: 60 minutes
Agenda:
Present audit findings (be factual, not blaming—this is system failure, not individual failure)
Review gap analysis and risk priorities
Identify "quick wins" (e.g., online training staff can complete this week)
Identify budget needs (external courses, cover costs for time out)
Assign gap-filling responsibilities to Training Leads
Set target: 95%+ compliance on statutory within 8 weeks
Outputs: Approved gap-filling action plan with owners and deadlines
Phase 3: System and Policy Build (Week 4-6)
Action: Update Your Staff Training and Development Policy
You need the policy framework to make this stick.
Key policy components:
Purpose: Why we have systematic training (patient safety, regulatory compliance, professional development)
Roles and responsibilities: Who owns training for each staff group (Training Leads), who maintains the tracker (Practice Manager), who approves budget (Partners)
Training categories: Statutory, professional, role-specific, development
Frequency and renewal: How often each category must be refreshed
Induction requirements: What all new starters must complete in first 3 months
Competency assessment: How we verify learning, not just attendance
Record-keeping: Where evidence is stored, how long kept (typically 6 years post-employment, varies by record type)
Monitoring and audit: Quarterly compliance checks, annual review
Funding and time allocation: How training is budgeted, how staff get time to complete it
Using My Practice Manager Tools:
Email Assistant (Fastest): Email mypm@automate.mypracticemanager.co.uk with:
"Generate a Staff Training and Development Policy for [Practice Name]. Include roles and responsibilities, training categories (statutory, professional, role-specific), induction requirements, competency assessment framework, and monitoring schedule."
You'll typically receive a policy document within a few minutes as an attachment. Customize for your practice structure and training leads.
Web AI Tools: Generate and edit at https://app.mypracticemanager.co.uk/ai-tools. Generation typically takes about a minute, with:
Alignment with CQC Regulation 18 requirements
Professional body standards (GMC, NMC, GPhC) integrated
Export in Word/PDF for approval
Compliance Library: Access template policies at https://app.mypracticemanager.co.uk/library (subscription required for full access). Templates include:
Staff Training and Development Policy — overall framework
Induction Training Procedure — new starter requirements
Competency Assessment Framework — how to verify learning
Training Needs Analysis Procedure — annual planning
For manual implementation: Create policy covering CQC Regulation 18, Health and Safety at Work Act, professional body requirements (GMC Good Medical Practice, NMC Code, GPhC Standards), and employment law on training provision.
Action: Build Your Competency Framework
Training certificates prove attendance. Competency assessments prove learning.
Competency verification methods:
Knowledge check: Brief quiz or verbal Q&A after training (e.g., "Describe the practice procedure if you suspect child abuse")
Observation: Watch staff perform the task (e.g., supervisor observes HCA taking blood, confirms technique is safe)
Discussion: Supervision conversation exploring understanding (e.g., "Tell me about a time you applied information governance principles in your work")
Reflective practice: Staff write brief reflection on learning and application
Practical approach:
Statutory/mandatory training: Knowledge check via brief quiz (5 questions per topic)
Clinical procedures: Direct observation by competent supervisor with signed competency checklist
Professional CPD: Evidence in professional portfolio (GP revalidation folder, NMC online account)
Non-clinical role-specific: Discussion in supervision (recorded in supervision notes)
Outputs:
Competency Assessment Framework document
Competency checklists for clinical procedures
Knowledge check quizzes for statutory training topics
Action: Establish Your Induction Process
Most training gaps come from new starters slipping through. Fix this systematically.
Your Document Package for Training System:
You'll need these documents from the compliance library to support your training system:
Policy: Staff Training and Development Policy — establishes framework, roles, requirements, and governance
SOPs:
Training Needs Analysis Procedure — systematic annual planning
Induction Training Procedure — new starter requirements
Competency Assessment Procedure — how to verify learning
Forms:
Induction Checklist — new starter tracking
Competency Assessment Checklist — clinical procedure sign-offs
Training Record Template — individual staff evidence capture
Audits:
Training Compliance Audit Checklist — quarterly verification
For My Practice Manager subscribers: Access these documents directly from our compliance library. Each document includes regulatory citations, implementation guidance, and version control. Use our tools to customize them for your specific practice context in minutes.
For manual implementation: You can create similar documents yourself, ensuring they address current CQC Regulation 18 requirements and professional body standards. Build in clear roles, audit schedules, and evidence requirements.
Comprehensive induction checklist:
Day 1:
Practice tour and introductions
Key contacts and escalation pathways
Emergency procedures (fire exits, first aid, emergency alarms)
IT systems access (email, clinical system read-only initially)
Week 1:
Role-specific buddy/shadowing
Key policies (safeguarding, IG, H&S, lone working, whistleblowing)
Clinical system training (EMIS/SystmOne basics)
Mandatory e-learning commenced (fire, H&S, IG)
Month 1:
All statutory training completed
Role-specific training booked or completed
Initial competency assessments done
First formal supervision session
Month 3:
All induction training completed
Competencies signed off
End-of-induction review with line manager
Confirmation of successful completion
Outputs:
Induction Checklist template
Induction Training Tracker (separate from main tracker during probation period)
Phase 4: Execution - Filling the Gaps (Week 6-8)
Action: Training Amnesty - Clear the RED and AMBER Gaps
Now the focused effort to get numbers up.
Approach:
For online/e-learning gaps:
Send all staff their individual gap list (private email, not public shaming)
Give clear deadline: "Please complete these 3 e-learning modules by [date 4 weeks away]"
Provide protected time: "You can use 2 hours of work time for this - arrange with your supervisor"
Weekly reminders via email or team huddles
Track completions in real-time on the Master Tracker
For external course bookings:
Training Leads book courses for their staff group
Practice Manager coordinates diary coverage
Course costs claimed from training budget
Certificates must be submitted to PM within 1 week of completion
For competency assessments:
Clinical supervisors schedule observation sessions
Use competency checklists to standardize assessment
Sign-off recorded in tracker and personnel file
Any gaps identified trigger additional training/supervision
Communication approach:
Positive framing: "We're investing in your development and ensuring you have the training you need to do your job safely and confidently"
Remove barriers: Provide time, budget, and practical support
Celebrate progress: Weekly updates showing compliance % rising
Address non-compliance: If someone refuses or repeatedly fails to prioritize, escalate through supervision
Using My Practice Manager Task Management:
Set up recurring tasks to maintain momentum and create audit trail:
Weekly: "Update training tracker with completions this week" assigned to Practice Manager (30 minutes)
Weekly: "Send reminder email to staff with outstanding RED gaps" assigned to Training Leads (15 minutes)
Fortnightly: "Review progress with Training Leads" assigned to Practice Manager (30 minutes)
End Week 8: "Prepare first compliance report for partners" assigned to Practice Manager (1 hour)
These automated reminders ensure nothing gets forgotten and provide clear evidence trail for CQC inspections.
Key metrics to track:
Statutory and mandatory compliance rate: Target 95%+ by Week 8 (including Oliver McGowan, Prevent, safeguarding, IG, fire, H&S, IPC)
Professional compliance rate: Target 100% (non-negotiable for regulated staff)
Role-specific compliance rate: Target 85%+ by Week 8 (some items may need external courses not yet available)
RED gap closure: Target 100% by Week 6
AMBER gap closure: Target 80%+ by Week 8
Phase 5: Monitoring and Continuous Assurance (Month 3+)
Meeting 3: Presentation to Senior Leadership
When: Week 8 (once initial gap-filling complete)
Attendees: Practice Manager, Training Leads, GP Partners, Practice Leadership Team
Duration: 45 minutes
Agenda:
Present the "before": Show initial audit results (e.g., "68% statutory compliance, significant gaps in safeguarding and IG")
Present the "after": Show current compliance (e.g., "96% statutory compliance, 100% professional compliance")
Show the system: Demonstrate the Master Tracker, explain ongoing monitoring process
Present the budget: Show training costs incurred, project future annual costs (for partner budgeting)
Highlight risks remaining: Any staff still non-compliant, upcoming renewal schedule, induction process robustness
Propose ongoing governance: Quarterly compliance reports to partners, annual training needs analysis
Visual aids:
Before/After bar charts: Compliance % by category
Role-based compliance: % compliance by staff group (shows where risks concentrate)
Monthly trend: Line graph showing improvement over 8-week implementation
Upcoming renewals: Forecast of training due in next 12 months (helps budget planning)
Outputs:
Partner approval of the training system
Budget confirmation for ongoing training costs
Agreement on quarterly reporting schedule
Recognition of achievement (this is good leadership work—make sure partners see it)
Action: Conduct First Formal Training Audit
Verify that your tracker reflects reality.
Audit scope (2-3 hours):
Sample systematically: Select 10 staff across different roles
Check their records: For each person, verify their tracker entries match actual certificates in file
Test the system: Are expiry dates calculated correctly? Is status accurate?
Check competencies: For clinical staff sampled, do they have competency sign-offs for procedures they're performing?
Review induction: For any staff who joined in last 6 months, verify induction checklist is complete
Audit findings:
Tracker accuracy: % of entries that match source documents
Completeness: Any training done but not recorded?
Induction compliance: % of new starters with complete induction
Competency compliance: % of clinical staff with up-to-date competency assessments
Outputs:
Audit report confirming system is robust
Action plan for any discrepancies (e.g., "Update tracker to reflect 3 training certificates found in files but not recorded")
Evidence for CQC: "We conduct quarterly training compliance audits with documented findings"
Action: Establish Ongoing Maintenance Schedule
Set up the recurring activities that keep the system running. These should be formally scheduled and assigned to specific roles.
Brief setup now, full schedule detail in "Maintaining the Improvement" section below.
Key activities to schedule:
Monthly: Tracker updates, expiry alerts, new starter checks
Quarterly: Formal audits, partner reports, Training Lead reviews
Annual: Full training needs analysis, policy review, budget planning
See the "Maintaining the Improvement" section for complete detail on each activity.
Common Problems and Solutions
Problem 1: "We don't have budget for all this training—some courses cost £300+ per person"
Why this happens: Training is seen as optional expense, not essential investment. Budget wasn't planned in advance. Practices underestimate the true cost of maintaining compliance.
How to address it:
Prioritize ruthlessly: Statutory and professional training is non-negotiable (budget must be found). Development training is "nice to have" and waits for budget availability.
Use free/low-cost options: e-LFH is free for NHS staff, many statutory topics have free e-learning, local safeguarding boards often offer free sessions
Make the business case: Show partners the cost of non-compliance (CQC enforcement, professional body sanctions, negligence claims) vs. cost of training
Spread costs: Don't try to fix everything in month 1—stagger expensive external courses over 12 months
Prevention: Annual training budget as fixed line item (commonly £3,000-8,000/year depending on practice size and service mix), built into partnership drawings from start of financial year.
Problem 2: "Staff say they don't have time to do training—we're too busy seeing patients"
Why this happens: Training added on top of existing workload. No protected time allocated. Culture of "patient care vs. admin" competition.
How to address it:
Reframe: Training is patient care—competent staff provide safer care. This isn't optional admin.
Protected time: Build into rotas (e.g., "Every Thursday morning, one admin staff member has 2 hours for training catch-up")
Flexible options: Online training can be done early morning, late afternoon, or at home if appropriate
Stagger it: Not everyone trains at once. Spread over weeks so workflow isn't disrupted.
Prevention: Training time built into job plans and annual rota planning. Recognized as legitimate work activity, not "time off".
Problem 3: "Our training records are scattered across ESR, BlueStream, paper files, and emails—it's chaos"
Why this happens: Multiple training providers, no central system. Historical lack of coordination.
How to address it:
Accept dual entry: You can't force NHS to integrate with your Excel tracker. Accept that you'll manually transfer from ESR to your tracker monthly.
Create one source of truth: Your Master Training Tracker is the definitive record for CQC purposes. Other systems are source data, but tracker is what you manage against.
Automate where possible: If ESR allows CSV export, import to your tracker rather than manual retyping
Staff responsibility: Make it staff responsibility to submit certificates to PM within 1 week of completion (written into training policy)
Prevention: Build tracker maintenance into someone's job description (typically Practice Manager or HR lead has this as ongoing responsibility).
Problem 4: "CQC inspected and said our training records weren't good enough—even though staff had done the training"
Why this happens: Evidence gap. CQC needs to see certificates and competency assessments, not just staff saying "I did that course years ago."
How to address it:
Certificate rule: No certificate = no credit. If training was done but not evidenced, it needs redoing (harsh but necessary for CQC compliance)
Prospective fix: From today forward, every training must be certificated and recorded immediately
Competency assessments: Retrospectively assess competency (even if training was years ago)—a current competency observation can partially mitigate missing training certificate
Show the system: Even if current records have gaps, showing CQC you now have robust system (tracker, policy, quarterly audits) demonstrates responsiveness
Prevention: Training policy includes clear evidence requirements. Staff trained to submit certificates immediately. Practice Manager does monthly chase for missing evidence.
Problem 5: "New starters keep slipping through without completing induction—then we discover gaps at 6-month review"
Why this happens: No structured induction process. Assumption that supervisor will "sort it out." Line manager forgets or gets too busy.
How to address it:
Mandatory Induction Checklist: Physical checklist given to every new starter on Day 1, signed off by supervisor at Day 1/Week 1/Month 1/Month 3 milestones
Practice Manager oversight: PM tracks all new starters on separate induction tracker, chases supervisors weekly if items not completed
Probation linkage: Successful completion of induction is formal requirement for passing probation (makes it non-optional)
Buddy system: Every new starter assigned experienced buddy who helps them navigate training requirements
Prevention: Robust onboarding process owned by Practice Manager, not delegated entirely to busy line managers.
Success Criteria and Evidence
You'll Know You've Succeeded When:
95%+ statutory and mandatory training compliance across all staff categories (fire, H&S, IG, IPC, safeguarding, Prevent, Oliver McGowan), with 100% target for patient-facing staff
100% professional compliance for all regulated staff (GP revalidation on track, nurses meeting NMC requirements, pharmacists meeting GPhC CPD standards)
All clinical staff have competency assessments for procedures they perform, signed off by qualified supervisors
Master Training Tracker is accurate and current, updated monthly with all completions and expiry dates correct
100% new starter induction completion within 3 months of start date
Quarterly audits consistently show >90% compliance, with action plans for any gaps
Training budget is planned and controlled, no last-minute panic spending before CQC inspections
Staff feedback is positive: "I know what training I need and I get time to do it"
Evidence You Can Show to CQC:
Documentation and governance:
Staff Training and Development Policy with version control and partner approval
Training matrices showing requirements by role
Induction checklists for all staff who joined in last 2 years
Competency assessment frameworks and completed assessments
Meeting minutes showing training discussed at governance meetings
The Master Training Tracker:
Current compliance status for all staff across all training categories
Evidence location for each training item (can produce certificates on request)
Expiry tracking showing proactive renewal process
Historical data showing improvement trend
Audit and assurance evidence:
Quarterly training compliance audit reports
Action plans for gaps identified and evidence of follow-up
Quarterly reports to partners showing ongoing monitoring
Annual training needs analysis and budget planning
Performance data and trends:
Dashboard showing compliance % by category over time (demonstrating sustained compliance, not one-off fix)
Induction completion rates for new starters
Professional compliance for regulated staff (100% GP revalidation on track, 100% nurse NMC compliance)
Competency assessment completion rates for clinical staff
Professional portfolios (for sampled staff):
GP revalidation folders with CPD certificates and reflections
Nurse NMC online accounts showing revalidation compliance
HCA competency folders with observation sign-offs
Individual staff supervision records showing training discussed
Maintaining the Improvement
Monthly activities (2-3 hours):
Update tracker: Add new training completions, update expiry dates
Expiry alerts: Email staff whose training expires in next 90 days ("Your fire safety training expires on [date]—please book renewal")
New starter tracking: Check all new starters are progressing through induction on schedule
Quick compliance snapshot: Calculate % compliance by category, flag anything dropping below 90%
Quarterly activities (3-4 hours):
Formal compliance audit: Sample 10-15 staff records, verify tracker matches certificates, check competencies are current
Partner report: Present compliance dashboard, highlight risks (e.g., "3 staff have revalidation deadlines in next 6 months"), confirm budget tracking
Training Lead review: 30-minute meeting with all Training Leads—share challenges, plan external course bookings, update matrix if needed
Policy check: Quick review that procedures still reflect reality
Annual activities (6-8 hours):
Training Needs Analysis: Full review of training matrix—add new requirements (new services, new regulations), remove obsolete items
Policy review and approval: Refresh Training & Development Policy, update for any regulatory changes, get partner sign-off
Deep-dive audit: Extended audit covering all staff categories and all training types
Budget planning: Project next year's costs based on renewal schedule, price increases, and any new training needs
Embedding the change:
Make it routine: Training compliance becomes business-as-usual, like payroll or QOF—systematic and unremarkable
Culture shift: Training is valued, not seen as burden. Staff ask about development opportunities in supervision.
New starter success: Every new starter has smooth, comprehensive induction—they feel supported and prepared
Continuous improvement: Use audit findings to refine (if induction checklist isn't working, improve it; if certain training provider is poor quality, switch providers)
Additional Resources
My Practice Manager Tools
My Practice Manager Email Assistant Get instant help throughout your implementation:
Generate role-based training matrices
Answer questions about professional requirements
Draft training policies and induction checklists
Review your existing training records and suggest improvements
No login required—just email your request
Example queries:
"Draft a training requirements matrix for 4 GPs, 2 nurses, 1 HCA, and 4 admin staff"
"What are NMC revalidation requirements for practice nurses?"
"Generate a Staff Training and Development Policy for [Practice Name]"
"What safeguarding level is required for GP receptionists?"
AI Document Tools Generate customised training documents in ~1 minute:
Staff Training and Development Policy
Training Needs Analysis Procedure
Induction Training Checklist
Competency Assessment Framework
Visual editing interface for detailed customization
Export in Word/PDF format ready for approval
Compliance Library (Subscription required for full access) Access complete training system templates:
Policies, procedures, checklists, and audit tools
Built-in regulatory citations (CQC Regulation 18, professional body standards)
Implementation guidance with realistic timescales
Regular updates reflecting regulatory changes
Task Management Automate your ongoing training compliance:
Monthly tracker update reminders
Quarterly audit schedule with email notifications
Individual staff training expiry reminders
Annual policy review and training needs analysis prompts
Never miss a deadline or compliance check
Related Improvement Plans
Related improvement plans covering complementary workforce management topics (coming soon):
Implementing Performance Management and Appraisals — systematic staff development and capability management
Improving Staff Wellbeing and Reducing Absence — proactive mental health support and absence management
Implementing Effective Supervision Systems — structured support conversations and professional development
Regulatory Guidance and Standards
CQC Requirements:
CQC Regulation 18: Staffing — Staff must have qualifications, competence, skills and experience to do their job
CQC Single Assessment Framework — Quality Statements used to assess training compliance and workforce capability
Professional Body Standards:
GMC Good Medical Practice — GP professional obligations including CPD
GMC Revalidation Guidance — CPD requirements for GP revalidation
NMC Revalidation — Nurse and midwife revalidation requirements (35 hours CPD, 20 participatory over 3 years)
GPhC Standards for Pharmacy Professionals — Pharmacist CPD and professional standards
Statutory Training Guidance:
UK Health Security Agency Infection Prevention and Control — IPC training requirements
ICO Data Protection Training — Information governance training
Intercollegiate Safeguarding Guidance (Children) — Child safeguarding levels by role
Intercollegiate Document for Adult Safeguarding (2018) — Adult safeguarding competency framework
Oliver McGowan Mandatory Training — Learning disability and autism training (Health and Care Act 2022)
NHS Prevent Training & Competencies Framework — Counter-terrorism awareness training
Getting Help
Having trouble with our tools? Our support team can help you set up training matrices, customize documents, and make the most of My Practice Manager features: help@mypracticemanager.co.uk
This improvement plan is provided as practical guidance for GP practice managers implementing systematic staff training compliance systems. While based on current regulatory requirements (CQC Regulation 18, GMC standards, NMC Code, GPhC standards), you must exercise professional judgment and adapt recommendations to your practice's specific circumstances, staff composition, and services provided. For HR legal advice or employment law questions, consult appropriate professionals.