Chemotherapy Competency Database - LTHT Medical, Nursing & Pharmacy

Publication: 01/03/2015  
Next review: 24/01/2022  
Standard Operating Procedure
ID: 4464 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2020  


This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

LTHT Medical, Nursing & Pharmacy Chemotherapy Competency Database

This SOP should be followed by all Registrar and Consultant level staff, Registered Nurses and Pharmacists, who are authorized to prescribe, verify and administer systemic anti-cancer chemotherapy for adult patients.


To standardise the recording of chemotherapy competency based training on a database which can be accessed on the hospital intranet for medical, pharmacy and nursing disciplines. http://lthweb/sites/chemotherapy

Back to top

Background and indications for standard operating procedure

This SOP should be followed to ensure patient safety in the prescribing, checking and delivery of chemotherapy for adult patients. The NHS England Quality Surveillance Measures: Cancer Chemotherapy: Adult (2018) mandates that the Clinical Chemotherapy Service must be able to provide current training records in each specific area of competence.

Back to top

Procedure method (step by step)

The Leeds Cancer Centre is responsible for:

  • Management of the chemotherapy competency registers.
  • Ensuring the chemotherapy register is kept up to date.
  • Informing the lead chemotherapy pharmacist, the senior chemotherapy nurse, the chemotherapy lead clinician and deputy as well as the CSU Matron and senior sisters in chemotherapy areas of updated key documents.

The chemotherapy database is split into three sections which include:

  • Chemotherapy prescribers register
  • Chemotherapy verification register
  • Chemotherapy administrators register

Only those staff members who have been trained and assessed as competent in a particular task and are named on the chemotherapy register for a given task in the chemotherapy process are permitted to perform that task within the trust.

The Leeds Cancer Centre will hold a list of medical, pharmacy and nursing staff with designated responsibility for authorising the entry of an eligible person onto that part of the register for that respective task. This list of competency assessors will be agreed by the chemotherapy medical, pharmacy and nursing lead for the Leeds Cancer Centre.

Back to top

Assessor of competence for prescribers (medical), and non-medical prescribers

Assessors of prescribing competencies must;

  • Be of consultant grade and work in Clinical Oncology, Medical Oncology or Haematology at LTHT.
  • Have been awarded a Certificate of Completion of Specialist Training (CCST) in Clinical Oncology, Medical Oncology or Haematology.
  • Have completed the online training modules for Educational Supervisors and attended the Supervising Trainees Workshop, or have evidence of equivalent training.

Inclusion on the database as an assessor is renewed annually and requires confirmation that the assessor;

  • Has prescribed/supervised the prescription of chemotherapy within the last 12 months
  • Has had an annual appraisal.
  • Is familiar with the current Chemotherapy Competency Levels and suggested assessments.
  • The above is confirmed by self-assessment and signed off by the Chemotherapy Lead Clinician.


Back to top

Assessors of competence for verification (pharmacist)

The criteria for acting as an assessor of competence are adopted locally at LTHT. Those responsible for assessment must meet the following criteria;

  • Spend at least 50% of their time practicing the competencies as defined in the LCC standard operating procedures for verification of chemotherapy.
  • Undertake regular CPD.
  • Have no areas of concern with their own practice e.g. acceptable error rates.

Back to top

Assessor of competence for chemotherapy administration (nursing)

Those responsible for assessment must meet the following criteria;

  • Hold a teaching & assessing qualification e.g. ENB 998, MIP, SLIP.
  • Must have given chemotherapy for over 18 months.
  • Must have completed a UKONS Safe Handling & Administration Trust Assessor Certificate. This form must be signed by approved SACT assessor, band 7 or above.
  • Must be chemotherapy competent themselves.
  • Assessors must be competent in the clinical skill which they are assessing e.g. if assessing a staff member in cannulation and giving bolus chemotherapy then they must also be skilled and competent in this task.

Refer to the LTHT Chemotherapy Administration Guideline

The management of the register will be coordinated by the Business Manager of the Leeds Cancer Centre, whose responsibility it will be to ensure the register is kept up to date.

This register will be updated on the hospital intranet on an on-going basis and will be available electronically.

  • Once the member of staff has been assessed as competent, the assessment form must be signed by both assessor and staff member.
  • The competency assessment sheet acts as the written confirmation that the member of staff has completed the training and is competent to be included on the register. This must include details of which part of the register the member of staff is authorized for, details of the member of staff and the date of signing and review date.
  • This document is retained by the member of staff and a copy with the assessor.

For consultant prescribers (not assessors) the following form should be used

For Registrar and Non -Medical Prescribers the forms can be accessed via

The prescribing competency SOP can be accessed for reference here

For nurses administering SACT the competency forms can be accessed via

A second copy of this document is forwarded to a clerical person who is nominated by the Business Manager of the Leeds Cancer Centre by the assessor. Once received by the Cancer Centre, the individual and their relevant details will be entered onto the register. Staff has access to this register which is updated within no more than one working day of a form being received by the Cancer Centre.

  • At their annual review of competence, or at any other time, the chemotherapy medical, pharmacy or nursing lead or the competency assessors have the authority to delete a staff member from the register.
  • The Leeds Cancer Centre will keep expired copies of staff’s competency check lists for 2 years after the current year of registration.
  • All staff will be re-assessed on their ability to remain on the register on an annual basis. Refresher training may be initiated prior to re-registration where appropriate.
  • Two months prior to the date re-registration is required, the Leeds Cancer Centre office will send a reminder to the member of staff. The member of staff will be expected to complete an assessment of competence again with their assessor. If satisfactory, the Leeds Cancer Centre should be notified by being sent copies of the completed competency assessment and the register updated accordingly. If no response is received a further reminder will be sent after 1 month. If the member of staff is considered to no longer be competent in this area, or if the documentation is not received, the person will be removed from the register.


Record: 4464
Clinical condition:
Target patient group:
Target professional group(s): Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

National Cancer Peer Review Programme. Manuel for Cancer Services: Chemotherapy Measures 2011.
Guidelines for the Checking, Administration & Handling of Systemic Anti-Cancer Treatment (November 2017)
Standard Operating Procedure for Adult Chemotherapy Competencies (June 2017)

Document history

LHP version 2.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.