Standards › Standard 2E › Policies
Policy · WRK-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 2E.1
At a glance
- Every workforce member is assessed against the competencies of their own job description at least once a year.
- Assessments use the forms for the role (WRK-FRM-001), signed by the staff member and the line manager.
- A competency gap always leads to a learning action with an owner and a date.
- Assessment results are kept in the personnel file and are not used for any other purpose without consent.
- Stop and get help straight away if: a staff member is working in a clinical role with no current competency assessment.
1. Purpose
To make sure every staff member is competent for the work they actually do, and that gaps are found and closed, not left unnoticed [EC].
2. Scope
| Applies to | All workforce members, paid and unpaid, including locums and volunteers in clinical roles |
| Locations | All services of the facility |
| When | At appointment, at each annual assessment, and after any change of role |
| Does not apply to | Students on placement (covered by their placement agreement) |
3. Definitions
| Term | Meaning |
|---|---|
| Competency | The knowledge, skill and behaviour needed to do a job safely and well |
| Job description | The written statement of duties and required competencies for a role |
| Competency gap | A required competency that the staff member does not yet show |
4. Background
Competence is not a one-time event. Practice changes, equipment changes and people change role. Criterion 2E.1 asks for regular evaluation against the actual job, not a certificate filed at appointment.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Chief executive | Approves the policy and receives the annual summary | Executive |
| Clinical and service managers | Run assessments for their teams on time; agree learning actions | Management training |
| Staff member | Takes part in the assessment and completes agreed learning | Own role |
| Human resources lead | Keeps the assessment schedule and the personnel records | HR administration |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Competency assessment form by role (WRK-FRM-001) | Current version for the role | Matches the job description |
| Job description | Current, signed | Dated within the last 12 months |
7. Safety
- A staff member who is found not competent for a task must not carry out that task unsupervised until the gap is closed.
8. Before you start
- Confirm the role’s job description and its competency list are current.
9. Procedure
Step 1. Schedule the assessment.
- Set the date at least 4 weeks ahead, for every staff member.
- Tell the staff member what will be assessed and what evidence to bring.
Key point: No one is missed. The schedule is checked each month.
Step 2. Assess against the job description.
- Use WRK-FRM-001 for the role.
- Observe or review evidence for each competency listed.
Key point: Assess what the person does, not what they say they do.
Step 3. Record gaps and agree learning.
- Write each gap on the form.
- Agree one learning action per gap, with an owner and a date.
Key point: A gap without an action is not closed.
Step 4. Check closure.
- Re-assess the gap when the learning action is due.
- Record the result and sign the form.
Key point: Closure is proven by a second assessment.
10. Decision points
- If a gap affects patient safety, the staff member is supervised or removed from the task until the gap is closed. The line manager decides and records the decision the same day.
11. Special situations
| Situation | Action |
|---|---|
| New staff member | Assessment is completed within the probation period, before independent practice. |
| Change of role | Assessment for the new role is completed before the change takes effect. |
12. Escalation
- A staff member who refuses assessment, or a gap that is not closed by its date, is reported to the clinical director and then the chief executive.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Staff assessed in the last 12 months | 100% | Monthly | Human resources lead | Escalate to clinical director |
| Gaps with a learning action and date | 100% | Quarterly | Clinical managers | Escalate to chief executive |
| Gaps closed by their due date | At least 70% | Quarterly | Clinical managers | Review the learning action |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| WRK-FRM-001 Competency assessment form | Personnel file | Employment plus the period set by the facility’s records policy years |
15. Training
- Managers who assess competency are trained in the method before they assess their first team.
16. Related documents
| ID | Title | Use |
|---|---|---|
| WRK-SOP-001 | Annual competency assessment procedure | How the assessment is run |
| WRK-FRM-001 | Competency assessment form by role | Record of each assessment |
| STF-SOP-001 | Staff qualification procedure | Qualification checks at appointment |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. Assessment frequency set by the ASF Expert Committee by the Committee. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)