First reported 8 Jan 2015•Latest report 19 Feb 2026
Definition
What this concern includes
Includes induction, role-specific training, qualification checks and competence assurance for temporary or agency staff assigned clinical or care duties.
Not included
Permanent staff training systems
Agency staffing shortages with no competence deficiency
Individual misconduct after adequate competence assurance
Reports
27
Distinct published reports
Individual concerns
35
A report can raise multiple concerns
Date range
2015–2026
First to latest report issue date
Stated actions
69
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care3
Ministry of Justice2
NHS England2
Bamford Grange Care Home1
Barchester Healthcare Limited1
Birmingham Community Healthcare NHS Foundation Trust1
Cardiff & Vale University LHB1
Cygnet Behavioural Health Limited1
Darnall Grange Nursing Home1
Essex Partnership University NHS Foundation Trust1
Frimley Health NHS Foundation Trust1
Frimley Park Hospital1
Gloucestershire Health and Care NHS Foundation Trust1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
Hc-One Limited1
NHS trust11
Ministerial department6
Private limited company6
Care-home operator2
Executive non-departmental public body2
Local health board2
Multi-service care provider2
Prison or young offender institution2
Type not available2
Healthcare site1
National policing body1
Nursing home1
Residential care home1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Surrey
Concerns raised1
Insufficient training of agency staff to record medical care on the ward computer system
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Require agency staff to complete online and classroom Epic training, including an end-of-training assessment, before working a Trust shift.
Stated by Frimley Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 June 2024.
Gloucestershire
Concerns raised1
Out-of-date medical training for bank staff
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Integrate bank staff work locations into training profiles to support accurate resuscitation training allocation.
Stated by Gloucestershire Health and Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2024.
Action
Use bank staff training-compliance information in e-rostering to ensure sufficient trained staff are available for each shift.
Stated by Gloucestershire Health and Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing rostering and compliance controls ensure sufficient fully trained staff are available each shift despite some individual training being out of date.
Stated by Gloucestershire Health and Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West London
Concerns raised1
Failure to train agency healthcare staff in the ACCT process and the threshold for opening an ACCT
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Write to Health and Justice regional teams sharing concerns and requesting action to ensure agency and bank staff access necessary joint training, including ACCT training.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 6 October 2023.
Action
Take the report’s findings to the NHS England Health and Justice Delivery Oversight Group for oversight of the proposed training-access action.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 6 October 2023.
Action
Require regional teams to provide assurance at the planned Health and Justice Delivery Oversight Group meeting that agency and bank staff have timely access to ACCT training.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 6 October 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
HMPPS is responsible for overseeing effective ACCT training delivery at prison establishments, including ACCT case manager and assessor training.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England is responding to concerns about prison healthcare staff training in the ACCT process.
Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Yorkshire Eastern
Concerns raised2
Failure to assure agency nurses’ competence, induction and handover
Reliance on agencies to assess the competence of supplied clinical staff
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Share and discuss RCA findings with the nursing agency and implement a competency checklist signed by agency staff and the supplier.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Action
Provide deteriorating-patient training to agency staff through the supplier competency process.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The RMO’s agency was considered best placed to assess whether the incident was isolated or required wider performance action or GMC escalation.
Stated by Spire Healthcare LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Inadequate falls risk assessment training during staff induction
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Create an action plan covering falls assessment, enhanced supervision training and falls-risk-assessment auditing.
Stated by Birmingham Community Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2023.
Action
Deliver an Essential to Role training week for new starters within two months of commencing, including falls and enhanced supervision training.
Stated by Birmingham Community Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2023.
Action
Update temporary-staff ward induction checklists to include essential falls-risk-assessment and falls-prevention content.
Stated by Birmingham Community Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2023.
Action
Audit temporary-staff induction checklists through Matrons and discuss findings at inpatient quality review meetings.
Stated by Birmingham Community Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2023.
Action
Use the launched Essential Care Framework to support clinical-team self-assessment and incorporate falls-training improvements into it.
Stated by Birmingham Community Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2023.
West Yorkshire Eastern
Concerns raised4
Failure to establish whether bank and agency staff hold current resuscitation training
Failure to establish the nursing qualifications of bank and agency staff permitted to work in the ED
Failure to provide a suitable induction system for bank and agency staff to become familiar with the crash call system
Lack of audits and spot checks verifying bank and agency nurses’ familiarity with crash call procedures
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Check for new temporary staff at every shift start and complete a signed first-shift induction covering emergency and resuscitation procedures, equipment locations and reporting processes.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The Trust disputes that the bank nurse lacked appropriate resuscitation training, stating that she had completed current mandatory Level 1 resuscitation training.
Stated by Leeds Teaching Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing qualification, training, induction, audit and spot-check arrangements are considered sufficient to ensure temporary ED staff understand emergency procedures.
Stated by Leeds Teaching Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Additional checks for substantive staff joining the bank are considered unnecessary because mandatory training compliance is regularly reported and reviewed through their substantive roles.
Stated by Leeds Teaching Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Swansea and Neath Port Talbot
Concerns raised1
Lack of regular access to ACCT training for bank nurses
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Make suicide and self-harm prevention training, including new modules, available to partner-organisation staff at HMP Swansea.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 20 September 2022.
Action
Reserve two places in each ACCT training session for Health Board staff.
Stated by Swansea Bay University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 20 September 2022.
Action
Prioritise and roster Health Board staff to attend ACCT Awareness training.
Stated by Swansea Bay University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 20 September 2022.
Action
Make ACCT training mandatory in induction for new prison Health Board staff and provide refresher access.
Stated by Swansea Bay University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 20 September 2022.
Action
Provide ACCT version 6 training to eight prison health staff.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Secure ACCT training places for medical staff as national training dates are released.
Stated by Swansea Bay University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Healthcare staff concerns are addressed by Swansea Bay University Health Board, the healthcare provider at HMP Swansea.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for ACCT training adequacy rests with the prison and will be addressed in the prison’s response.
Stated by Swansea Bay University Local Health BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East London
Concerns raised1
Use of nursing staff without training or experience in NG tube management
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Revise the Trust induction policy to require assurance that temporary staff are competent for their allocated patient care.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.
Action
Configure the temporary-staff booking system to record specialist skills and prevent bookings that do not meet requested skills.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.
Action
Develop and provide a comprehensive local induction pack for new temporary clinical workers.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.
Action
Improve the knowledge and skills of the nursing workforce and verify that temporary surgical staff meet service and safe-practice requirements.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.
South Wales Central
Concerns raised1
Gaps in agency nurse training and understanding of septic screening procedures
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Surrey
Concerns raised1
Failure to ensure agency staff are familiar with the Head Injury Policy
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Provide an agency folder containing key policies and require agency nurses to review and sign acknowledgment during induction.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 30 December 2019.
Action
Disseminate the revised agency nurse induction procedure through staff notices and individual briefings.
Stated by Barchester Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 30 December 2019.
Action
Complete spot checks of agency nurses’ knowledge to test understanding of the relevant policies.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 30 December 2019.
Action
Develop a pocket guide summarising key points from ten policies, including head injury and falls policies, with FAQs and advice contacts for agency staff.
Stated by Barchester Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 30 December 2019.
Action
Introduce a wall-mounted poster providing key policy information for staff in each home.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 30 December 2019.
Action
Print and introduce a modified agency worker induction checklist across all Barchester homes, incorporating the pocket guide once available.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 30 December 2019.
Action
Monitor compliance with the revised agency induction checklist through Regional Director checks and the Barchester audit programme.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 30 December 2019.
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Includes induction, role-specific training, qualification checks and competence assurance for temporary or agency staff assigned clinical or care duties.
