INDUCTION POLICY - sfh-tr.nhs.uk

Induction Policy Version: 8 Issued April 2018 Page 1 of 48

INDUCTION POLICY

POLICY

Reference INDT POL TED

Approving Body Training, Education and Development Committee

Date Approved 12th March 2018

Issue Date 1st April 2018

Version 8

Summary of Changes from Previous Version

Changes to local induction checklists for new and temporary/agency and locum staff.

Supersedes

7

Document Category Human Resources

Consultation Undertaken

TED Committee, HR Business Partners and NWB.

Date of Completion of Equality Impact Assessment

10th March 2018

Date of Environmental Impact Assessment (if applicable)

10th March 2018

Legal and/or Accreditation Implications

NA

Target Audience

All staff including agency and locum staff.

Review Date 1st April 2020 Further extended to 31/12/2021

Sponsor (Position)

Executive Director of HR and OD

Author (Position & Name)

Deputy Director of Training, Education and OD

Lead Division/ Directorate

Corporate

Lead Specialty/ Service/ Department

Training, Education and OD

Position of Person able to provide Further Guidance/Information

Deputy Director of Training, Education and OD

Associated Documents/ Information Date Associated Documents/ Information was reviewed

Not Applicable Not Applicable


CONTENTS

Item Title Page

1.0 INTRODUCTION 3

2.0 POLICY STATEMENT 3

3.0 DEFINITIONS/ ABBREVIATIONS 3

4.0 ROLES AND RESPONSIBILITIES 4

5.0 APPROVAL 6

6.0 DOCUMENT REQUIREMENTS 6

7.0 MONITORING COMPLIANCE AND EFFECTIVENESS 7

8.0 TRAINING AND IMPLEMENTATION 9

9.0 IMPACT ASSESSMENTS 9

10.0 EVIDENCE BASE (Relevant Legislation/ National Guidance) and RELATED SFHFT DOCUMENTS

9

11.0 APPENDICES 9

APPENDICIES

Appendix 10

Equality Impact Assessment 47


1.0 INTRODUCTION 1.1 It is essential that all new permanent staff joining the organisation attend a Corporate

Induction (Orientation Day) course prior to starting their employment.

1.2 After completing the Corporate Induction course, all new staff must make sure that they are given a local induction into their working area by their line manager. All new staff that change role or departments within the Trust must also undertake a local induction into their new area and complete a local induction checklist.

1.3 This policy applies to all staff that are new to the Trust or existing staff that are taking up a new post within the Trust. This policy is designed to provide guidance on the principles and good practices important in ensuring that all staff receive an appropriate and quality induction.

1.4 This policy is issued and maintained by the Executive Director of Human Resources and OD on behalf of the Trust and supersedes and replaces all previous versions.

2.0 POLICY STATEMENT 2.1 Induction to the Trust - Corporate Induction (Orientation Day) All permanent staff new to the Trust must receive a general induction to the Trust within 4

weeks of their start date which will include corporate objectives, values, priorities and an understanding of key organisational workings.

2.2 Induction to the Post - Local Induction

Information and training specific to an individual’s role must be given to all new permanent staff, those taking up a new post within the Trust, and Board members through a structured induction programme within 4 weeks of their start date. Temporary, agency and volunteer and medical staff will receive specific inductions as outlined in Appendix 4, 5, 6, 7 and 8 respectively.

3.0 DEFINITIONS/ ABBREVIATIONS 3.1 Corporate Induction (Orientation Day) The Corporate Induction (Orientation Day) programme is designed to provide an overall

introduction to the organisation, its strategic objectives, priorities, values, behaviours and information relating to staff facilities and support. Appendix 3 contains a list to topics and content covered by the Corporate Induction programme.

3.2 Induction to the Post - Local Induction Local induction is designed to establish clear foundations and expectations of new staff

or staff that have moved job roles within the organisation in terms of understanding their role, mandatory training requirements and the working practices of their department.


4.0 ROLES AND RESPONSIBILITIES 4.1 Induction to the Trust - Corporate Induction (Orientation Day) 4.2 Line Managers

It is the responsibility of all Line Managers to ensure that new members of staff are recruited to start work on the agreed set start dates and that duty rotas/shift pattern/hours of work for permanent members of staff allow for full attendance on the Corporate Induction (Orientation Day) programme. It is the responsibility of Line Managers to monitor and check that all new permanent staff have attended the Corporate Induction (Orientation Day) programme when completing the local induction process and checklist.

4.3 Recruitment Team

The Recruitment Team are responsible for inviting and booking new permanent members of staff on to the Corporate Induction (Orientation Day) to the Trust via the recruitment system, Trac. A copy of the booking is also sent to the line manager.

A list of staff due to attend Corporate Induction (Orientation Day) is made available on Trac for use by Training & Development.

If a new member of staff fails to attend the Corporate Induction, their line manager is contacted by the Recruitment Team advising them of non-attendance. The Recruitment Team will send out a new invite via Trac to the member of staff inviting them to attend the next Corporate Induction, as appropriate following discussions with the line manager.

If a new member of staff does not attend Orientation Day without giving prior notice of non-attendance then it is assumed that the new member of staff has not accepted the offer of employment at the Trust.

4.4 Training, Education and Development Department

Staff within the Training, Education and Development Department oversees the facilitation, programme content and delivery of the Orientation Day programme at the Trust.

4.5 It is the responsibility of the Training, Education and Development Department to monitor

and record attendance on the programme via an attendance register which is then used for recording onto the OLM system. The Dept will also undertake regular reviews of the content of the Corporate Induction (Orientation Day) programme to ensure that it reflects organisational objectives and the needs of attendees.


4.6 Induction to the Post - Local Induction

Line Managers The Line Manager is responsible for ensuring that:

New members of staff are welcomed to the Ward/Department, including both new employees to the Trust and staff who are transferring from another ward or department.

A structured local induction programme is undertaken with all new permanent staff, those taking up a new post within the Trust and volunteers. During this process the Line Manager will complete the induction checklist in Appendix 2 for non-medical staff, Appendix 6 for medical staff and Appendix 5 for volunteers and confirm mandatory training required for the post will be identified. A separate induction process exists for nursing, HCA and specialist clinical staff who attend a specific induction course immediately after the Orientation Day course. Other clinical staff will receive local specialist inductions into their areas which are outside the remit of this policy.

All elements of the Local Induction Check List (Appendix 2) must be completed within a maximum of 4 weeks from appointment for all permanent staff and 4 weeks for temporary members of staff (Appendix 4).

New permanent members of staff, those taking up a new post within the Trust and volunteers will be given adequate time to undertake all of their required mandatory training and that other training relevant to the individual and role is addressed within an appropriate timescale.

For admin and clerical staff, non-medical and non-nursing clinical staff, the induction checklist is completed and signed off at the first review meeting within 4 weeks after appointment and a copy filed within the individual’s personal file. A copy must also be sent to the Training, Education and Development department for monitoring and recording on the Trust’s OLM database.

Where staff persistently fail to complete the induction process this should be considered as a performance management issue and managers should contact their local HR adviser for further advice.

4.7 Individual Staff

Staff must take responsibility for identifying aspects of their role or information needs with which they require help before they consider themselves fully competent.

Staff must not carry out any procedure or activity for which they have not been sufficiently trained and are not competent to perform.


4.8 Responsibility for Monitoring Completion of the Induction Process

The following people are responsible for monitoring completion of the induction process:

Line Manager - All staff new to a post

Voluntary Services Manager - Volunteers

Company Secretary - Board Members

Locum doctors - Rota Co-ordinators/Hospital and Night Team Leader

Nurse in charge - Agency nurses

4.9 Medical and Nursing Staff See Appendix 6 for permanent medical staff inductions and Appendix 7 and 8 for locum inductions. Separate local induction procedures exist for the induction of registered nurses, midwives, healthcare assistants and certain multi-professional staff are covered through the registered nurse and health care assistants induction programmes.

5.0 APPROVAL

5.1 The Training, Education and Development Committee are responsible for approving,

updating, monitoring and developing the Trust's Induction Policy. 6.0 DOCUMENT REQUIREMENTS 6.1 Legislation and Guidance

All relevant legislation and national guidance has been taken into account and referenced in the development of this policy.

6.2 Impact Assessments

The relevant impact assessments have been completed in relation to this policy, see Appendix 10.

6.3 Consultation

Consultation has been carried out with senior nursing and medical managers, HR Business Partners, key training and development leads and the Head of E-Rostering.

6.4 Communication

This policy and any subsequent changes made to the policy will be communicated via the staff bulletin and targeted to key managers and specialist leads within Trust.


7.0 MONITORING COMPLIANCE AND EFFECTIVENESS 7.1 All induction checklists will be reviewed bi-annually by the Training, Education and Development Committee to ensure that they

reflect national and professional guidelines and organisational requirements. 7.2 For all permanent admin and clerical, non-medical and non nursing-clinical staff copies of the local induction checklists should be

sent to the Training Department for logging on the OLM system within a maximum of 4 weeks of starting in their new position. 7.3 Monitoring of local induction processes and nurse agency checklist compliance will be monitored by the Training, Education and

Development Department through the OLM reporting systems. Reports will be sent to ward leaders on a monthly basis as part of performance monitoring to ensure that local inductions are carried out for new staff.

Where local inductions have failed to be completed it is the responsibility of the line manager to ensure their completion.

Departmental managers will be sent copies of monthly performance reports as part of the follow up process. A local induction checklist will not be recorded as being completed until assurance that the new member of staff has attended a corporate induction course and all of the information on the local induction checklist has been completed.

7.4 For temporary nurse agency staff, induction check lists (Appendix 4) will be completed by the nurse in charge of the

ward/department and returned to the Training and Development Department within 4 weeks of the employee starting. Compliance monitoring will be carried out on a monthly basis by the Training and Development Department using the procedure contained within Appendix 4.

7.5 For volunteer members of staff, all induction checklists should be sent to and monitored by the PALs manager. 7.6 For all permanent medical staff, induction checklists should be sent to and monitored by Divisional HR Business Partners as per

Appendix 6. For Doctors in training completed check lists should be sent to and monitored by the Medical Education Department. Rota Co-ordinators will monitor locum induction checklists, Appendices 8 and 9.

7.7 The Training, Education and Development department sends monthly local induction compliance monitoring reports to the

Divisions for non-medical and non- clinical staff. 7.8 The Temporary Staffing Office will carry out monthly compliance audits of locum induction checklists and send monthly reports to

divisional clinical chairs and the Matron for Hospital at Night.


7.9 The Information and Quality team within the Training, Education and Development Department will undertake a 6 monthly audit of 20 new permanent and temporary staff members over 6 months to ensure that:

Booking onto the corporate induction took place.

Completion of corporation induction course was completed in 4 weeks and local inductions for permanent and temporary staff were completed in the time frame as stated in the policy and checklists received.

That new permanent and temporary members of staff have been recorded as having completed their corporate and local inductions onto the OLM recording system.

Where permanent and temporary members of staff have failed to complete their corporate and local inductions, appropriate follow up and escalation processes have been followed

Minimum Requirement

to be Monitored

(WHAT – element of compliance or

effectiveness within the document will be

monitored)

Responsible Individual

(WHO – is going to monitor this element)

Process for Monitoring

e.g. Audit

(HOW – will this element be monitored (method used))

Frequency of

Monitoring

(WHEN – will this element be monitored

(frequency/ how often))

Responsible Individual or Committee/

Group for Review of Results

(WHERE – Which individual/ committee or group will this be reported to, in what format (eg

verbal, formal report etc) and by who)

Local induction check list for permanent non medical and non-clinical staff

TED Department Completion of induction checklists

Monthly Line managers and Directors – Included in mandatory training reports.

Local induction check list for agency nurse staff

TED Department Completion of returned agency induction checklists Summary of completed agency induction checklists

Monthly Bi-monthly

Ward Leaders – formal report Matrons, Chief and Deputy Chief Nurses – formal report

Local induction check list for locums

Temporary Staffing Office Completion of induction checklists

Monthly Clinical Chairs and Matron for Hospital at Night


8.0 TRAINING AND IMPLEMENTATION To be communicated to all staff and managers via the Trust Bulletin. 9.0 IMPACT ASSESSMENTS

This document has been subject to an Equality Impact Assessment, see completed form at Appendix 10.

This document is not subject to an Environmental Impact Assessment 10.0 EVIDENCE BASE (Relevant Legislation/ National Guidance) AND RELATED SFHFT DOCUMENTS Evidence Base:

NHSLA Standards Related SFHFT Documents:

Mandatory Training Policy 11.0 APPENDICES Appendix 1 Induction procedure for permanent staff

Appendix 2 Check List for Local Induction to the Post non-medical

Appendix 3 Example of Orientation Day Programme

Appendix 4 Temporary Staff Induction Checklist -

Appendix 5 Volunteer Induction Checklist

Appendix 6 Permanent Medical Staff Induction procedure and checklist

Appendix 7 Locum Induction Checklist &

Appendix 8 Emergency Department Checklist

Appendix 9 Trainee Junior doctor specialty induction checklist

Appendix 10 Equality Impact Assessment


Appendix 1

Procedure for the Induction of Permanent Staff to the Trust The following principles and good practices should be followed for the induction of staff to the Trust. 1.1 All permanent staff new to the Trust attend an orientation programme on

their first day of employment. 1.2 Staff are informed of the orientation programme arrangements within

their letter of appointment which is sent out by the Central Human Resources.

1.3 All staff are required to sign an Orientation Day attendance register

which is monitored by the Training, Education and Development Department.

1.4 Signed registers of attendance from the Orientation Day programmes

are retained within the Training, Education and Development Department.

1.5 Staff non-attendance on the Orientation Day programme is monitored by

the Central Human Resources Department who will then advise the new member of staffs line manager accordingly. The Central Human Resources Department will send out a new letter to the new member of staff inviting them on to the next Corporate Induction course if appropriate. An admin and clerical, non nursing-clinical/medical local induction checklist will be completed after the employee has completed their orientation and within 4 weeks of their start date and compliance is monitored by the Training, Education and Development Department divisional monthly reporting system.

1.6 Each Orientation Day programme is evaluated and attendance is

recorded onto the Trust's OLM training database. 1.7 In the event of speakers being absent from the Orientation Day, a letter

is sent to the individual’s line manager listing the subjects which were not covered and information on how this training can be accessed.

1.8 Facilitators of the Orientation Day programme are regularly sent a copy

of the summary of evaluations to ensure the content of their session is monitored and improved where necessary.

1.9 The content of the Orientation Day programme is reviewed regularly in

order to ensure that organisational objectives are reflected. 1.10 Different procedures apply to medical staff locums and temporary staff

and volunteers. See Appendices 4, 5, 7 and 8.


APPENDIX 2

Check List for Local Induction to the Post

(Permanent staff non-medical and non-clinical)

The following induction checklist for newly appointed permanent non clinical and non-medical staff must be completed within 4 weeks of the new employee starting. It is not intended as a complete list for all areas and there will be additional topics which are specific to departments or professions which should also be covered as part of the induction process. Each topic must be ticked when discussed and each section initialled by the manager when completed.

Areas for

Discussion Topics to be Discussed

Topic discussed and understood

First Day

Check employee has attended Orientation Day

(Corporate Induction), if not contact the HR Dept.

Check completion of pre-induction e-learning

programs.

Personal email address/passwords issued.

Departmental security (Keys, door and alarm codes,

Fire Safety and evacuation) and 2222 number.

Uniform.

Hours of work, on-call and cover arrangements for leave.

Introduction to team members and overview of

departmental/divisional structure.

Information on key contacts/communication networks.

Expectations and responsibilities of the role.

Departmental policies and procedures including financial procedures, booking annual leave, sickness reporting and special leave

Relevant departmental information and procedures.

Staff side representatives.

Planned developments for the department/area

Where to seek help and advice.

Appraisal information

It is good practice to allocate an experienced member of

the department to advise and support the new member

of staff as a mentor/coach/buddy

Signed


Name of staff member Start date: Date of checklist

completion Name of Line Manager Department Signature of line manager Signature of employee

Please send this signed and completed form to the Training, Education and Development Department for recording onto the OLM system within 4 weeks of

an employee starting.

Risk Management and other Mandatory Training for the post

Moving and Handling awareness

Mandatory training requirements of the role as

identified in the Mandatory Training Policy

Reporting Procedures (Incidents/Accidents)

Departmental specific procedures

Trust and Departmental risk management systems

No Smoking Policy

Details of Departmental and Trust Health and

Safety procedures and Business Continuity Plans.

Information Governance

Infection Control standards and practices

Complete the E Learning DSE and workstation

assessment if staff member regularly works with

display screen equipment for more than two hours

in a working day.(state NA if not appropriate)

Signed

Quality Standards

Clinical/Professional/Departmental standards

Minimum standards of performance expected in the role linked with the KSF post outline/CARE values

Appropriate records to be kept and information resources available

Human Resources and Training

How to access H.R. advice

HR procedures - including Whistle blowing and

Bullying and Harassment

Accessing Training, Education and Development

The first Development Review meeting should take place 6 to 8 weeks after appointment. Appraisals should be followed up at 30, 60 and 90 days.

Trust Information

How to navigate the Trust Intranet site and where to find key information.

How to access Trust Policies


APPENDIX 3

ORIENTATION DAY PROGRAMME

9.00am Registration 9.30am Welcome, Introduction and Housekeeping followed by People

Bingo 9.45am Chief Executive Welcome 10.15am Trust Vision and CARE Values 11:00am Break 11.15am Fire Lecture 11.45am Dementia Awareness 12.20pm Spiritual and Pastoral Care 12.30 Lunchtime Fayre 1.15pm Risk Management 1.45pm Infection Prevention and Control 2.15pm Human Resources 2.30pm Freedom to Speak Up Podcast 2.45pm Major Incident Planning 2.55pm Basic Life Support 3.00pm Valuing Our Employees 3.15pm Evaluation and Close followed by Optional Tour

Prior to staff attending Orientation Day, new starters are required to complete mandatory e-learning packages on Information Governance, Safeguarding Adults, Moving & Handling, Health, Safety and Welfare, Counter Fraud Safeguarding Children, Diversity and Inclusivity and Channel Awareness (PREVENT). Registered nurses also complete Adult Oxygen Therapy.


APPENDIX 4

TEMPORARY/AGENCY NURSE/HCA/CLINICAL/THERAPY STAFF

GUIDELINES FOR INDUCTION

The nurse in charge will use the checklist below to induct temporary staff and must be completed after handover and before the agency nurse/temporary clinical/therapy staff has any patient contact. The Ward Leader or nurse in charge will issue an Induction Card to the agency member of staff. The agency member of staff will then need to produce this card when they are next booked to work on a shift to prove validation of induction. If no card can be produced then the full induction will need to be completed again before they are allowed to work. The Induction Card will be valid for 3 months. Once the Induction Card has expired then a full induction will be completed and a new Induction card for that month will be re-issued. Due to the nature of the wards at Kings Mill, Mansfield Community and Newark Hospitals, one induction card will cover all wards.

Once the checklist has been completed, a copy must be sent to the Training, Education & Development Department, Kings Mill Hospital within 4 weeks of completion.


TEMPORARY NURSE/HCA/CLINCIAL/THERPAY STAFF

MONITORING AND AUDIT PROCEDURE

Step One

All Agency temporary staff data is sent to the Professional Education and Training Team on a monthly basis from individual agencies.

Step Two

Copies of the Temporary Staff Induction Check Lists are returned to the Training and Development Department for recording. The paper based

checklists will be stored in the Training Department.

Step Three

A monthly audit will be carried out to check the returned Temporary Staff Induction Check Lists against names received from the Agencies.

Step Four

The Training and Development Department will send a letter Ward /Department Leaders on a monthly basis who are not complying with the Induction Policy

relating to temporary staff. The letter will identify temporary staff who have not received an induction.

Step Five

The Training and Development Department will send outstanding audit results to the Heads of Nursing and Divisional Matrons on a bi-monthly basis for

monitoring so compliance gaps can be addressed.


TEMPORARY, AGENCY NURSE, CLINICAL/THERAPY STAFF INDUCTION CHECKLIST Name (Please Print)

Role & Agency

Ward/Clinical Area Date of shift

Please use correct induction list relating to the temporary member of staff’s role.

Agency Nurses

Temp HCA

Temp Clinical

Staff

Temp Therapy

Staff

Completed

Please as appropriate

1. Have you had Level 2 or above Safeguarding Training or relevant Safeguarding update within the last year? NB: If NO the worker is unable to continue working and must be sent off duty and TSO and Agency informed

YES / NO

2. Orientation to the Ward/clinical area

3. Fire Procedure, (exits and evacuations)

4. Cardiac arrest and urgent help procedure - Dial 2222.

5. Location of both Resus Trolley and Sepsis boxes

6. Procedure for use of the Sepsis Screening Tool and application of Sepsis 6 Protocol.

7. Procedure to contact an on call doctor

8. Nurse Call System & Vocera

9. MRSA screening swabs

10. NEWS & AVPU Observations

11. VIP scoring

12. Medical Equipment

13. Moving and Handling Equipment

14. Pharmacy Procedure to include IVI Policy

15. Admission Documentation

16. Discharge Procedure

17. FM Helpdesk number 3005

18. Pneumatic Tube system

19. NERVE Centre familiarisation

20. Positive & Negative Isolation

21. Security Procedures, (smartcards, ID Badge, agency name badge) Swipe Card

22. Bare below the elbows policy / Uniform Policy

23. Incident reporting

24. Complaint procedure (Patients)

25. Sickness reporting if booked for more than one shift

26. PAS and IT Systems Access

27. Sharps injuries and disposal of sharps

28. Red Tray System

29. Correct procedure for cleaning a commode

30. Demonstrate the correct hand hygiene technique

Temporary / Agency Workers Signature…………………………………………………………..Date……/……/…… Induction completed by: (Please print name)………………………………………………….. Signature and Date ……………………………………………………….……………………… Date……/……/……

Once Completed please send a copy to Training, Education & Development Department, Level 1, Education Centre

Date returned:…………………………..


APPENDIX 5

Community Involvement Department

King’s Mill Hospital Mansfield Road, Sutton in Ashfield

Nottinghamshire, NG17 4JL Direct dial: 01623 – 676011

Switchboard: 01623–622515 Ext 3154 or 3521

Name of volunteer:

Induction date:

No. Subject

1 Welcome letter from Community Involvement Manager

2 Fire & Security Procedures & ID Badge Authorisation

3 Health and Safety

4 Infection Control

5 Confidentiality & Data Protection

6 Safeguarding Adults

7 Safeguarding Children & Young People

8 Using Social Media Responsibly

9 Patient Experience Team

10 Privacy & Dignity

10 Foundation Trust Membership

11 Information on Sherwood Forest Hospitals (NHS) Foundation Trust

12 Our shared values and behaviours

13 Uniform & dress code information

14 Smoke Free Information

15 Equality & Diversity

16 General Information

17 Welcome from Volunteer Governor

18 Volunteer Constitution

All of the above information has been discussed with and understood by me.

Volunteer signature _______________________________ Induction Date _____________ Co-ordinator signature _____________________________ Date ______________

Issue Date: 01/2018 Review Date: 01/2019 Ref: CID/VS/IND/1


APPENDIX 6

GUIDELINES FOR THE INDUCTION OF MEDICAL STAFF

1.0 INTRODUCTION

Induction welcomes new employees to the Trust and aids their integration into the

team. The initial welcome to the Trust makes new staff feel valued and ensures that

the staff embraces the values of the Trust. A good induction ensures that employees

are competent and are integrated speedily into the organisation.

Induction to Sherwood Forest Hospitals Foundation Trust (SFHFT) for all grades of

medical staff will be a process that both complies with regulatory requirements and

adds value to the training of the staff. The process will be streamlined to be similar

and appropriate for all grades of medical staff. Responsibility for ensuring that

corporate induction for all training grade doctors is delivered will rest with the Medical

Education Department, as will the responsibility for the maintenance of record

keeping. For non-training grade doctors and consultants the responsibility for ensuring

that corporate induction is delivered rests with the HR Business Partner for the

respective Division.

On completion of the corporate induction, the Divisional HR Business Partner will be

responsible for ensuring that the appointed representative of the respective Divisions

who will deliver the departmental induction meets the new medical staff member/s.

This departmental induction must take place prior to the new medical staff member/s

commencing clinical duties. Medical Education will arrange all departmental

inductions for doctors in training.

2.0 SCOPE

All medical staff newly appointed to the Trust will be inducted via the same

process. The responsibility for inducting doctors who move between specialties

within the Trust will rest with the Divisions to which they transfer.

The Medical Education Department or appropriate HR Business Partner will

arrange corporate inductions and ensure that new members of staff are directed to

the appointed representative of Divisions for the departmental induction.

The Medical Education Department will maintain records of induction for Doctors

in Training. HR Business Partners will maintain records on consultants and non

training grades doctors.

Induction will be a combination of personal contact and a web based process.

Induction will welcome staff to the Trust.


Induction will include all

required statutory training, awareness of corporate aims and policies and an

understanding of patients’ rights and HEE polices for doctors in training.

Induction will cover the Specialty specific aims, risks and policies.

Induction will include an assessment of the learning needs of the new employee.

The specific needs with regard to equipment and resuscitation training will be

assessed, documented and training arranged as appropriate.

3.0 PROCESS

The following identifies the required components, many of which are the same,

despite the separate routes of entry to the Trust, that need to be applied for the

induction process to be carried out effectively.

3.1 Foundation Programme and Specialty Training Doctor Induction

Trainee induction will occur four times a year on the first Wednesday of February,

April, August and December. The main induction process in August will consist of

one full day and the trainees will not be rostered for work during that time and the

days will be bleep free. Attendance will be compulsory and will be completed on the

day of induction. No trainee will be allowed to work in a specialty without receiving a

formal induction. Local inductions into the specialities will be completed within a 2

week period.

The generic induction process will involve the following

Completion of HR and IT department documentation

Exposure to Trust policies such as bullying and harassment, whistle blowing and

consent with signposting to intranet policy repository

Exposure to appropriate infection control and health and safety legislation

Following the patient journey through the hospital

Completion of the web based package (as appropriate and prior to employment)

Introduction to Specialty leads

Networking

Completion of a written commitment from each doctor to read and comply with all

relevant Trust policies

Further Specialty inductions will be completed as well as an educational induction

using a specialty induction checklist, appendix 9. A resuscitation training exercise will

be carried out as part of mandatory training if appropriate. If the assessment

indicates a need for training in the use of certain equipment this will be arranged by

the Resuscitation Training Department as soon as the request is received.


The Medical Education department will monitor and record all trainees inductions to

the Trust and specialty inductions. Trainees who fail to complete their induction

processes will not be allowed to commence work in the Trust/specialty and will be

contacted by the Medical Education Department to ensure that the appropriate

induction takes place.

The Medical Education Department will monitor and record compliance relating to

trainees being booked onto and completion of Trust and local inductions through their

quality monitoring systems. Where a trainee has failed to complete their speciality

induction with 2 weeks of starting, the Medical Education Department will contact the

trainee and service director to ensure completed checklists are returned to the

Medical Education Department.

3.2 Specialty Registrar (and doctors commencing outside main induction periods)

Induction

Specialty Registrars will be written to and booked onto the induction programmes by

the HR department.

Specialty Registrars arriving at the Trust will report to the Education Centre on their first day of work where a member of the HR department and a member of the Medical Education team will meet them. The generic process of corporate induction will be completed.

Once the induction has been completed, the Medical Education team will hand the

inductee over to the rota coordinator for the Division and the rota coordinator will

arrange for the trainee to complete the Specialty induction for the specialty in which

they will be based. Once the trainee has completed the induction process they may

begin work. Evidence of the completion of educational induction and assessment of

learning needs should be returned by the doctor to the Medical Education Department

by the end of week 4. If the assessment indicates a need for training in resuscitation

or in the use of certain equipment this will be arranged by the Resuscitation Training

Department as soon as the request is received. Completion of that training must be

documented within one month of the start date at the Trust. Induction checklists will

be kept and monitored by the Medical Education Team. Failure to complete this

process within 6 weeks will trigger a follow up process to the rota coordinator from the

Medical Education Team.


3.3 Non Career Grade Doctors Induction

New Non Career Grade Doctors will be written to and booked onto the Orientation

Day programme by the divisional HR advisors. The responsibility of completing the

generic induction process remains with the Division. Medical Staff Induction checklists

will be administered, kept and monitored by the Divisional HR advisors. Specialty

inductions will be completed by the nominated lead Consultant for the Division in

which the new employee will be based.

Evidence of the completion of a job plan including a personal learning plan and

assessment of learning needs should be returned to the Divisional HR Advisor by the

end of week 4. If the assessment indicates a need for training in resuscitation or in

the use of certain equipment this will be arranged by the Resuscitation Training

Department as soon as the request is received. Completion of that training must be

documented within one month of the start date at the Trust.

Induction checklists will be kept and monitored by the Divisional HR advisors. Failure

to complete this process within the 6 week period will trigger a follow up process to

the consultant and Service Director/Head of Service from the Divisional HR Advisor.

3.4 Consultant Induction

New consultant staff will be written to and booked onto the Orientation Day

programme by the divisional HR advisors. The responsibility of completing the generic

induction process remains with the Division. Medical Staff Induction checklists will be

administered, kept and monitored by the Divisional HR advisors.

Evidence of the completion of the induction checklist should be completed by the end

of week 4 and will be monitored by the Divisional HR Advisor. Failure to complete this

process within the 4 week period will trigger a follow up process to the consultant and

Service Director/Head of Service from the Divisional HR Advisor. If the assessment

indicates a need for training in resuscitation or in the use of certain equipment this will

be arranged by the Resuscitation Training Department as soon as the request is

received. Completion of that training must be documented within 6 weeks of the start

date at the Trust.

3.5 Locum Doctor Induction

The relevant division rota-co-ordinator will be responsible for booking a locum

consultant and for out of hours cover the Site Co-ordinator will be responsible for

booking the locum. It will be the responsibility of the rota co-ordinator to carryout the

induction checklist, as specified in appendix 7 before the locum doctor commences

work during working hours. For locums working in the Emergency Department a

specialist induction checklist in Appendix 8 will need to be completed and will be

carried out by the ED Consultant.


Locums who fail to complete the induction process satisfactorily will not be employed

by SFHT, this decision will be made by the Consultant lead or Hospital at Night Team

Leader as appropriate. Locums who return to the same speciality within a 6 month

period will not be required to complete the induction process again provided that it has

satisfactorily been completed on their first visit to the area.

Responsibility for inducting locums out of hours will be the responsibility of Hospital at

Night Team Leader.

Rota co-ordinators will be responsible for monitoring the completed induction

checklists once a locum has been contracted. In the unlikely event that a locum has

been allowed to work without completing an induction within 4 weeks of appointment,

the relevant Service Director will be notified by the rota co-ordinator and an induction

will be completed if the locum is still employed by the Trust.

4.0 RESPONSIBILITIES

Responsibility to ensure that all staff undergo induction rests with the Service Director/Head of Service for each Division.

Completion of Induction for Doctors in training will be organised and monitored by the Medical Education Department in liaison with the HR Medical Staffing Co-ordinator/HR Manager and nominated medical education lead of each Division.

The Divisional HR Advisors will be responsible for monitoring and keeping copies of records of all inductions undertaken for permanent medical staff.

Rota co-ordinators will be responsible for arranging and monitoring locum inductions.

Each Division will be responsible for providing and maintaining the material to update the Specialty section of their Intranet web site.

Individuals are responsible for familiarising themselves with the induction material provided and will be required to give a written undertaking to do so and to comply with Trust policies.

For Doctors in training, failure to complete the induction process or to attend mandatory training, as evidenced by the failure to receive completed records, will lead the Medical Education Department to notify the appropriate line manager. The initial response will be to offer another training opportunity. Failure to attend on the second occasion without just cause will be dealt with by the normal Trust disciplinary process.


Permanent Medical Staff Induction Checklist Consultants, Associate Specialist, Specialty Doctors

Name

Grade

Specialty

Date

CORE INDUCTION

Task Delivery Discussed/completed

IT Training Face to face

Intranet Discussion

E-mail Discussion

Library Discussion

Study leave Discussion

ID Badge and Access Card Collection

Smart Card Collection

Car Parking Discussion

Contract Collection

Occupational Health Appointment

Rota Co-ordinator Appointment

Signed

Designation

Date


HUMAN RESOURCES INDUCTION


Role of HR Business Partner Discussion

Pay services/Pension Discussion

Proof of ID Documentation

GMC registration & renewal Documentation

National Insurance Number Documentation

P45 Documentation

CRB Disclosure Documentation

Certificate of completion of HCAI training Documentation

Certificate of completion of blood

transfusion training

Documentation

Leave entitlement and booking leave Discussion

Telephone user Documentation

Notice period Discussion

Travel arrangements Documentation

Roles of Executive Medical Director and

Divisional Clinical Chairs.

Discussion

Trust Policies


Sickness Absence procedures Trust Intranet

Staff Health and Wellbeing Trust Intranet

Equality and Diversity Trust Intranet

Complaints Trust Intranet

Whistle blowing (Raising Concerns) Trust Intranet

Safeguarding Children and Adults, MCA and

Prevent

Appointment with

Safeguarding leads

EWT Trust Intranet

Grievance and discipline Trust Intranet

Harassment and bullying Trust Intranet

Information Governance Trust Intranet

Signed

Designation

Date


DIVISION/SPECIALTY INDUCTION

Organisational Issues


Overview of organisation Discussion

Aims and vision of organisation Discussion

Function of departments Discussion

Departmental policies & procedures Discussion

Divisional rules Discussion

Clinical roles/responsibilities/procedures Discussion

Line manager accountability Discussion

Hospital Vocera system Discussion

Appraisal, revalidation and educational

supervision

Discussion

Research & audit Discussion

Job planning Discussion

Mandatory training requirements Discussion

Health and Safety and Clinical


Fire policy & evacuation procedures Trust Intranet

Fire lecture Lecture

Health & Safety policy Discussion

Manual handling Trust Intranet

Consent policy Discussion

Sharps policy Trust Intranet

Violence and aggression Trust Intranet

Radiation control Trust Intranet

Infection control and bare below the elbows Trust Intranet

Resuscitation Policy and AND Trust Intranet

Clinical incident reporting Discussion

Hospital Clinical pathways/Protocols Trust Intranet

Hospital Infection Control Policy Trust Intranet

Hospital Antibiotic Policy Trust Intranet

PACS/Orion/Ice Discussion

VTE, NEWS, Nerve Centre / Sepsis 6 Bundle

awareness/assessments Discussion

Mental Capacity Act and two stage test Discussion

Medical Equipment overview and training

needs assessment Discussion


Supporting Functions


Pharmacy Discussion

Referral protocols Discussion

PALS Discussion

Medical Education Department Discussion

Training and Education Department Discussion

HCSA/BMA Discussion

Audit and governance leads Discussion

GMC Discussion

Royal College Reps Discussion

Healthcare Commission Discussion

LNC Discussion

Meetings


Head of Service/Consultant Lead Meeting

Governance Lead Meeting

Divisional Clinical Chair Meeting

Equipment (Specialty to complete)


Defibrillator/Dynamap Adult/Paediatric (various models)

Discussion

Resus Trollies Adult/paediatric SFHT Discussion

PACS Results System SFHT – Pathology system Discussion

Blood Glucose Monitor SFHT – Pathology system Discussion

Blood Gas Analyser SFHT – Pathology system Discussion

Resuscitation Equipment Orientation Medicine Surgery Emergency Dept Anaesthetics Obs & Gynae Paediatrics

Resuscitation

Trolley

Resuscitation

Trolley

Resuscitation

Trolley

Resuscitation

Trolley

Resuscitation

Trolley

Resuscitation

Trolley

XL & AED

Defibrillators

AED

Defibrillators

XL

Defibrillators

XL & AED

Defibrillators

AED

Defibrillators

AED

Defibrillators

PREM system PREM system Resuscitaire PREM system

Resuscitaire

Signed

[Doctor] [Grade]

[Divisional/

Specialty Lead] [Designation]

Date

This form (original) must be returned to the Divisional HR Business Partner within the

designated timescale of commencement date. A copy must be placed on personal

file.


APPENDIX 7

LOCUM DOCTOR INDUCTION CHECKLIST

NAME OF DOCTOR

GMC number

Department working in Date

Tick box

Tour of department incl pattern of working

Relevant staff members (middle grade and nurse in charge)

Fire procedures

PACS/Orion/Ice/e-prescribing and Nerve Centre

How to bleep/vocera

Referral guidelines, National Early Warning Score (NEWS)

Prescriptions – see leaflet

Medical Equipment awareness including Resuscitation Trollies

Adult protocols inc Mental Capacity

Safeguarding Children and Adults procedures

Children’s protocols incl HV liaison

Antibiotic drug policy (Intranet)

Specific care pathways eg stroke,

Clinical guidelines – see intranet

Sepsis 6 Bundle/application of Sepsis 6 protocol

Incident reporting (see leaflet) & Raising Concerns (Whistleblowing)

Hand hygiene

Infection Control and bare below the elbows policy

Needlestick injuries

Information Governance awareness

Evidence of completing Blood Transfusion E-Learning Modules 1,2 and Consent within last 2 years

Consultant call in criteria and accessing Registrar support

VTE assessment /Thrombolyis

Consent procedures – see leaflet

Handover procedures

I have read and understood the information above and I agree to follow this and not to work beyond my capability and competency.

Signature of Locum Doctor

Name of person carrying out induction

Signature of person carrying out the induction

Date

Please return this form to rota co-ordinators, Level 1, Kingsmill Hospital


APPENDIX 8 Emergency Department Locum Induction Checklist

EMERGENCY DEPARTMENT LOCUM INDUCTION CHECKLIST

NAME OF DOCTOR

Date GMC Number

I confirm that I am up to date with this training.

Training requirement Tick box if up to date

Mental Capacity

Safeguarding both children (further information on Paediatric intranet website ) and Vulnerable adults

Evidence of completing Blood Transfusion E-Learning Modules 1,2 and Consent within last 2 years

Consent procedures and Information Governance procedures

Infection control and needle stick injuries

National Early Warning Score (NEWS) –note that all patients that have observations on admission to ED require discharge observations

Sepsis and sepsis 6 bundle

Infection control and needle stick injuries

Hand hygiene, infection control and bare below the elbow policy

If I have not had this training then I agree to work to my competency and to seek support when required. Specific ED protocols re Escalation and Safety – if you identify any concerns re patient safety it is your responsibility to highlight this to Senior Staff and to report this via Incident Reporting (tick box if covered)

Incident reporting

Consultant call in criteria

ED Escalation Plan

Emergency Care Standards

Expectations of the Middle Grade in Charge overnight


Computer Systems

Tick box if done

ED IT system and PACS

Coding (you will not be paid unless your coding is up to date when you leave)

Radiology requesting

Protocols

Tick box if done

Adult protocols

Paediatric protocols including Safeguarding

Antibiotic protocols

Specific care pathways – CVA and TIA

Specialist clinics – ICR, Hot clinics for Resp, Gastro and EAU

CDU protocols

Inter – Consultant referral system

To Demonstrate Tick box

Tour of department - minors - majors - resus - Children and Young people’s Area

Inc. - pattern of working, fire procedures

Relevant staff members (middle grade and nurse in charge)

ED documentation

Equipment Inc. ABG machine and defibs

How to bleep/vocera

I have read and understood the information above and I agree to follow this and work within my competency

Signature of Locum Doctor

Name of person carrying out induction

Signature of Inducting Middle Grade or Consultant

Send one copy of this form to Rota Co-ordinations office, Temporary Staffing Office,

Level 1 Education Centre, King’s Mill Hospital



Some of the expectations/tasks of a locum Doctor Record Keeping

Write legibly – bad writing is not a badge of honour.

Write who you are; what you are writing about; what the time is; where you are; sign &

print your name at the end with contact details

Sticker at the top of each page, on at least one side – or write 2 patient identifiers e.g.

name and hospital number

Record everything you do

VTE assessment & prescribe appropriately

Capital letters for prescriptions

Course length for antibiotics

Use the BNF

Prescribe Oxygen where required

Consent

Any doctor at any grade can consent for a procedure so long as they understand the procedure and risks associated. You will receive training in your specialty induction for procedures appropriate for that speciality. When consenting any patient, you must ensure and record their capacity to make the decision. Use the two stage capacity test to ensure that you are happy that the patient has fully understood the planned procedure and record this in the notes, as well as ticking the box on the consent form to show that you have confirmed capacity. Record in the notes any discussions with the patient, relatives etc.


Reporting Incidents and Concerns If you witness or are part of an incident or patient safety risk/near misses, you have a responsibility to report this. It is not about getting anyone in trouble, but about identifying areas where for example, systems or protocols create the opportunity for error, so that these can be dealt with. You may not always receive personalised feedback because of the volume or incidents that are reported all the time, but sometimes the feedback exists in the form of a new pathway or system introduced as a result of incidents that have been reported.

11. You must follow the procedure where you work for reporting near misses and incidents. This is because routinely identifying incidents or near misses at an early stage, can allow issues to be tackled, problems to be put right and lessons to be learnt.

GMC – Duties of a Doctor: Raising Concerns

Handover When handing over or discussing a patient, whether with a senior for help or to the next shift of doctor cover for example, remember to use the principles of SBAR to ensure that you give the pertinent information and any thoughts that you have regarding management going forward.

Pathways

On the intranet there are a multiple pathways for the management of frequently occurring conditions. These are intended to assist in the management of these conditions and ensure that all patients get consistent and high quality treatment.


The pathways are to be found on the SFH intranet in Quick links, under Pathways and cover multiple

areas by speciality. E.g. there is a Geriatrics section which is where you will find the Confusion/delirium pathway

Sepsis Pathway

In addition, you will need to use the Sepsis pathway. You will find that most patients coming in from ED have been screened at that point, however, Sepsis may develop later and you will be required to initiate treatment as per the guidelines for Sepsis. The pathway for this appears a below. There should be copies on the ward or you can print it from the intranet. Simply type Sepsis into the search box and print the appropriate flow diagram – the one below is the adult version:


The Do’s and Don’ts of the ED

Do your coding when you see the patient – do not do it at the end of your shift

Do not discharge patients in Majors or Paediatrics without telling the Nurse in Charge – the patient will require discharge observations and if the patient is in Minors and had initial observations done they will require discharge observations and may and help with transport.

If you have any concern re patient safety do tell the Nurse in Charge or the Consultant in Charge

Do not write an x-ray card without seeing the patient first and documenting this in the notes

Do ask Senior Staff for support if you need advice

Do not write up more morphine if a patient has had 10mg morphine in the previous 1 hours (only MG and Consultants can do this).

Do click on to the assigned doctor in System One before starting to see the patient

Do not take advice from ‘SHO’ level doctors – advice should be from ED Consultants or Middle Grade. If they are not available ask for advice at Middle Grade level, not SHO level

Do tell the Nurse in Charge or the nurse looking after the patient the management plan for the patient.

Do not discharge patients without knowing the results of Troponin if a Troponin has been taken. Document the results of both Troponin in the notes and D-dimers

Do document times and dates of patient review in the notes. Also Do document the name of the clinician that you are handing over to in the notes and on System One

Do not leave without handing your patients over

Do discuss with x-ray staff if an x-ray has been ‘starred’ but you cannot see an obvious fracture – often there is a fracture present that is subtle that you have not seen.

Do not label blood tubes at the central area in Majors – this should be done at the bedside of the patient

If you are not happy with the advice of a doctor from other specialities – do ask either ED Consultant or MG.

Do not eat food or drink in the ED where you can be seen by patients (except for water)

Do take blood in accordance with Trust identification procedure and infection control procedures – see intranet site for this. Do not label blood tubes at central area in Majors

Do have a low threshold for x-ray in patients with neck, facial and hip injuries.

Do look up the hospital antibiotic policy and write the name of the antibiotic in the notes

Do report any safeguarding concerns to the ED Consultant or MG or Nurse in Charge

Do tell the nurses when patients are admitted to ward or referred to clinic – they will require an escort for transfer


Basic Codes of Practice 1 At all times the patients confidentiality and privacy should be respected. 2 If you are not happy that you have the experience to look after a patient with a particular condition you need to get help either from the middle grade doctor or the consultant on call 3 Patients are not to be ‘told off’ for attending the department even if it would have been more appropriate for them to see their GP 4 There is no such thing as a ‘quick look’ for assessing the patient. In the early stages of trauma and illness potentially ill patients can look as if they are well 5 It is good medical practice to examine the patient before reviewing x-rays. Review your own x-rays if possible. 6 Good note keeping is a sign of good medicine – documentation is paramount. Time and date entries as soon as you have seen the patient. Document the name of the doctor if you have asked anyone for advice and if you have handed the patient over for review 7 Previous medical care or contact with the GP should not be criticised especially the referral of the patient to the department. If there are strong feelings this should be brought to the attention to the Consultant and they will deal with it. 8 Do not sign for any analgesia without asking for a pain score and indications and contra-indications. It is also important to re-evaluate the patient’s pain after analgesia. Do not write up nebulisers without asking for a peak flow. 9 If you are asked to look at an ECG and there is a significant abnormality it is your responsibility to get the patient assessed appropriately 10 It is your responsibility to check blood results on your patient and also if the patient has been handed over to you for review. 11 At all times you need to be dressed appropriately – look up the hospital dress code policy on the intranet if you need to check what is appropriate Generic Information About the Department The Emergency Department provides care for the population of Mansfield, Ashfield and surrounding area. We have approximately100,00 thousand attendances per year and 22% of these are children. We observe patients with head injuries on the either the Emergency Assessment Unit or the Clinical Decision Unit. Competencies At all times you should be working within your level of competency. All other staff members in the ED are also working within their level of competency. This includes ENPs and ACPs. ENP are trained to see musculoskeletal injuries and so have criteria of which category of patient they can see. If you are asked to see a patient by an ENP or ANP when they have started the initial assessment but they are not able to see the patient due to their competencies then you need to fully review the patient and you are then responsible for them e.g. an example of this is paediatric patients under 1 year with limb injuries.


Discharge of Patients Patients that are assessed to be suitable for discharge must be discussed with the ED Consultant (in working hours) or ED Middle Grade if they are Non-traumatic Chest pain Fever in Child less than one year old None planned re-attendance within one week If the patient has been admitted via their GP ONLY a Consultant can agree for discharge (in working hours). Patient that have observations taken on admission require observations on discharge even if the initial observations were within normal limits. Admitted patients On transfer they should have discharge observations and an escort to the ward or the clinic if they are attending a clinic. Individual Care Plan’s If a patient has an individual care plan either documented in the ED notes, Medical case notes or brought with the patient this should be followed. The exception to this is the ED Consultant (or Middle Grade with agreement of the Senior Nursing Sister in charge of the shift) can override this in the best interest of the patient. Coding This is important for the department due to ‘payment by results’. If you do not do your coding the department does not get paid for the patients you have seen. Code the patient when you have a plan for the actual outcome i.e. admission under speciality or discharge. Four Hour Target This is important as we are judged on this by the rest of the hospital If you can anticipate there will be problems with this let senior staff or nursing staff know – they can expedite the process If you require an urgent blood test back let the nurses know so they can chase the results Ordering of Blood tests and Radiology on System One We now have electronic ordering of blood tests on ICE. This is for radiology, biochemistry and Haematology. Blood transfusion requests and microbiology forms have to be done on the paper form in the department. Blood transfusion tubes need to be hand labelled with the patient’s name, date of birth and hospital D number. If these are not on the tube the lab will not process it. Note it is difficult for other tests to be added on once the samples are in the machine and so need to be careful to ask for all tests on the request form Blood samples should be taken following Trust Procedure. The ICE label should be printed out before. The patients identity should be checked and then the bloods taken. The labels should be put on at the patient’s bedside. If there are blank bloods tubes at the station next to computers these shall be placed in the bin and the patient will require more bloods taken


Blood Results Often by the time you have seen the patient the nurses will have taken the blood tests at triage. If you need other blood tests and the nurses are very busy it is easier if you do the blood test themselves – by the time it is possible for the nurses to do this it can be an hour later and this can affect the four hour target Occasionally we send the patient home before the blood tests are ready – if you want to do this you need to discuss with Middle Grade or Consultants DO NOT SEND THE PATIENT HOME IF THEY HAVE HAD A TROPONIN TAKEN – YOU NEED TO GET THE RESULT BACK BEFORE YOU CAN DISCHARGE THE PATIENT If you discharge the patient and the blood results are not back it is your responsibility to make sure the blood results are checked Radiology Requesting ‘SHO level’ locum – should discuss potential scans with either MG or Consultants’ MG can request scan but if not clear indication to scan should be discussed with Consultant if present in the ED or with the on call speciality when the Consultant is not present. CT PA and CT KUB can be ordered up till 8pm and will be done on the same day. Between 8pm and 8am for CT requests discuss with the Radiographer to see if the scan can be done within their protocols. If after discussion the scan cannot be done within protocol you will be advised to contact the On Call Radiologist.

Infection Control The trust adheres to the national bare below the elbows policy and we expect you to follow the correct infection control procedures. This means no watch and only one plain band on finger. High Risk Indicators for MRSA

Previous MRSA infection / colonisation Inpatient stay in the last six months Patient with long term urinary catheter or indwelling line Admitted from a nursing home or residential home Chronic skin wounds or ulcers

If the patient is being admitted and they are high risk for MRSA you need to inform the nursing staff as the patient will require swabs taking and they will need to have infection control measure in place.

If the patient has diarrhoea and is Bristol Stool Chart number 7 or 8, again you need to let the nurses know as they will be treated as possible C. Diff and therefore will need samples taken and Infection Control measure in place.


Examining patients You need to wash your hands before and after every patient contact or use alcohol gel (if the patient has diarrhoea you need to wash your hands) Interventions e.g. Cannulation or blood cultures If you are doing an intervention on a patient we expect you to wash your hands and then wear gloves. You also need to clean the skin using the wipes containing 2% chlorhexidine and wait 30 seconds for the skin to dry. For doing blood cultures you need to follow the hospital policy. A separate site needs to be used and you need to clean the skin as above. For giving intra-venous medication we expect you to wash your hands, wear an apron and wear gloves. You then need to clean the port with a sterile wipe Documentation and Clinical Governance Issue We have regular audits regarding documentation and Quality Indicators. Please write legibly in black ink. Print your name at the top of the sheet and sign at the bottom. When you have formulated a plan make this clear on the notes. If you review a patient or refer to a speciality write the time down and sign again. Audit forms safety For all in hospital cardiac arrests can you please fill in the Cardiac arrest audit form We also have an Allow natural death protocol – again please fill in this form for all patients Police Statements If a patient has been assaulted we are often asked to provide a statement. This becomes much easier for us if you can document the injuries e.g. 2.5 cm wound on the right lower lip as opposed to cut on the face Discharge Information If you are discharging patient need to make sure they have the appropriate discharge information Patient questions answered Advice leaflet as required When to return – what to look out for if becoming worse Analgesia advice Advice re driving or work Clinical Information Asthma If a nurse asks you to write up a nebuliser your first response is to ask what the Peak Flow When you go and see the patient, you need to work out the severity according to the British Thoracic Guideline – if severe or life threatening move the patient to resus and let middle grade know. They will decide if the patient requires a blood gas or a CXR.


Pain Scoring If the nurses ask you to write up medication ask for pain score – use this to decide which type of analgesia to use If you go and see patient that has had analgesia please check the pain score yourself and document it Overdoses If taken paracetamol need to document the total dose and any risk factors for the high risk treatment line present Document which treatment line you have used Antibiotics The trust antibiotic policy is found in the trust intra-net on the Sherwood Forest Homepage. The trust is moving away from using broad spectrum antibiotics as this increases the risk of Health Care Acquired Infections. Therefore use the policy to guide your choice of antibiotics. If you prescribe an antibiotic for the patient to take home with them write down the name of the antibiotic. If a patient has been recently admitted to the hospital can look up the discharge letter on Orion (the hospital results reporting system) to find out recent treatment. If a patient is being admitted to the wards they may not be seen for some time by the relevant speciality – therefore package the patient as much as possible. If they require intravenous antibiotics they should get the first dose in the department. Domestic Violence and Safeguarding Remember to consider if there is possibility of domestic violence – need to know if there are children involved. Safeguarding Children Issues If you have concerns you can find out further information on the Paediatric Intra-net site. There are referral criteria for the above – again discuss with nursing staff You can refer to Health Visitor Liaison - fill in form and leave orange sticker on notes Social Services Paediatric Registrar Elderly patients being discharged post-Midnight A patient above the age of 65 years, if they are from a Care home can be discharged at any time of the day. If they are being discharged home they should be given the choice. If they do not want to be discharged late at night they should be transferred to EAU and transported home at 9am.


Referral Guidelines To Bleep dial 77, then bleep number of the person you want, then the phone extension number then the hash symbol on the phone. If the bleep has been accepted the tone will warble. If there is a straight tone then it has not been accepted For cardiac arrest call 2222 – ED do not routinely put the cardiac arrest call out For trauma call dial 2222 Trauma Calls - The Nursing Staff are under strict instructions to put the Trauma Call out should they feel it necessary. The only person that can stand down the Trauma Call is the ED Consultant if they are at the bedside of the patient. Emergency Assessment Unit All Medical admissions are transferred to the EAU unless they have been accepted to a Speciality bed e.g. NIV, Stroke or Cardiology. ED patients that are admitted as a head injury go to EAU when AECU is not open or when they are not suitable for AECU. Anaesthetics If wanting airway support - Anaesthetic Registrar on call. It is also good practise to call ODP. If there is a potential difficult airway definitely call ODP as well. If wanting to admit to ITU or HDU – ITU Registrar on call or call ITU. Patients that are admitted to ITU/HDU also need to be seen by the appropriate speciality.

Medical Admissions We now have new ways of working with the Medical team on call. The first on call Medical Doctor is based in the department. All patients that have been referred to the ED by their GP for a potential medical admission are seen in the ED. Patients can be ‘Senior Streamed’ to the on call Medical team if they are suitable patients for admission. This is normally done by Consultants or Senior ED Medical Staff. Otherwise they are seen by ED staff and then the decision is taken to discharge or admit them. If patients are potentially for discharge but they have been referred in by their GP this needs to be discussed with either Consultant if they are in the ED or MG before discharge. For all patients that are admitted to the On Call Medical Team the 1st on Medical Doctor needs to be informed of the definite admission and of outstanding issues e.g. x-rays to be reviewed or drug charts to be filled in. Even with patients that are referred to the Medical Speciality takes eg Respiratory, Cardiology and Gastro, the 1st on call needs to be informed. If you need advice or you want a sick patient to be reviewed in Resus by the Medical Team On Call then contact the Medical Reg Can also bleep the Medical SHO on 623 Please note if urgent advice re Cardiology patients then at KMH there is 24/7 on call by Consultant Cardiologist.


Surgical Admissions If there is a letter from a GP requesting a surgical review, the patient should be assessed by the On Call Surgical team Otherwise all potential surgical patients should be assessed by ED first and then referred if appropriate. Refer to the surgical 1st On Call Surgical Doctor – go through switchboard for bleep number Vascular Surgery is now based at QMC and so all vascular patients are referred to QMC. However if there is a patient with a diabetic foot infection unless they need urgent surgery they are referred to the on call Medical team who will obtain a vascular opinion the following day. Patients with potential AAA should have a CT organised and then when confirmed should be discussed with Vascular on call at QMC. Do not cross match 6-8 units of blood as this may delay transfer. If blood is required then it should be O negative bloods. The priority is transfer of the patient to QMC. Middle grade and above have admitting rights to SAU – can admit if a definite surgical referral, patient has everything done and patient not sick enough to require resuscitation. It is still advisable to contact the surgical 1st On Call Surgical Doctor to tell them the patient is going to be admitted so they are aware of them

Orthopaedics Refer to the orthopaedic SHO on bleep 411 Chest injuries are admitted under orthopaedics if they have a significant mechanism of injury or significant injury . See intranet protocol Back pain is admitted under Orthopaedics– the policy is on the ED intranet site For flexor tendon or nerve injuries refer to The Royal Derby Hospital – go through switchboard and ask for hand fellow on call Plastic Surgery Based at Nottingham City hospital – go through switchboard. Ask for the on call Reg

Paediatrics Refer to the Paediatric Registrar on bleep 495

Maxillo-facial There is no on call at KMH for this. For referrals contact Max –fax for advice/follow up planning. For facial wounds refer to ENT when ENT on call at KMH


ENT Refer to ENT on Mondays to Thursday from 8am to 12mn bleep 543 Out of hours refer to the ENT service at QMC For weekends refer to QMC from 4pm on Friday until Monday morning Can obtain ENT clinic appointments out of hours by leaving the notes at reception

Ophthalmology During daytime on call from KMH use on call sheet or contact eye clinic (clinic 8 KTC) Out of hours – can be on call either from KHM or Chesterfield – go through switchboard to find out

Obstetrics and Gynaecology Obs SHO bleep 220 Gynae SHO bleep 232 Obs and Gynae Reg go through switchboard or see on call list Mental Health Now staffed 24/7 – go through switchboard to access RRLP – If the patient has self-harm or overdose then they must be assessed by an ED Clinician

ED Admissions Head injuries are admitted under the care of ED to EAU or AECU All head injuries that require admission to the ward under the care of ED require discussion with the ED Consultant or Middle Grade. Often it is better arranging a CT scan than admitting. If the patient is admitted The head injury documentation needs to be filled out The drug card needs to be filled in including the throboprophylaxis chart – this includes regular analgesia and the patient’s normal medication Base line FBC and U&E need to be done Consider also whether an ECG needs to be done Specific Protocols AECU protocols ED protocols Head injury Overdose (with one medication only) Intoxication Mechanism of Injury Burns (do not require transfer to NCH) Post sedation


Medical Protocols – inform Medical on call team as they will need to review on AECU Chest pain PE Anaphylaxis Anaemia Cellulitis Pyelonephritis Trauma There is a trauma team for this. The protocol is found on the intranet and if the team is called an audit form should be filled in. The criterion is based on the physiology of the patient, the anatomical injuries and the mechanism of injury. STEMI The ED does not routinely thrombolyse patients now. These patients should be picked up pre-hospital and transferred directly to Nottingham City hospital for PCI. However occasionally this is not recognised by the ambulance crew or the patient self presents. In these situations if the patient is safe for transfer we call a blue light ambulance or keep the same crew and transfer them to NCH. Do not discuss with NCH Cardiology if the patient requires transfer. Arrange the ambulance and then contact NCH to inform them the patient is being transferred. This is to avoid potential delay from the processes of discussion. If the patient is not stable we discuss with Cardiology here and then at NCH to discuss possible transfer/ optimisation before transfer. KMH has 24/7 on call by Consultant Cardiology Stroke Patients that are suspected of having a Stroke are put into the stroke protocol. We are putting systems in place to begin thrombolysing patients with stroke. Please see the ‘stroke care pathway’ on the hospital intranet. When patients are initially assessed if they fit the criteria for CT scan and for thrombolysis they need a CT organised as early as possible (need to assess the ABC’s and make sure they have no airway problems – otherwise they will require an anaesthetic assessment before scan). For organising the CT we do not need to speak to the Radiology Consultant on call. We organise the scan with the radiographers who will contact the Radiology Consultants for the report. We also need to

(1) Fill in the stroke form (2) If they do fit the criteria they are admitted directly to the Stroke Unit and the relevant

investigations are taken. During the day time Monday to Friday we contact the Stroke team.


Stroke thrombolyis is based in KMH Monday 24/7 TIA Assess the patient clinically and calculate the ABCD2 score – this is the ED intranet site under forms. If the patient is high risk this should be discussed with the Stroke ward and the patient will be given an OPD next working day – follow the instructions on the form If the score is less than four fill in the TIA form and follow the instructions. Leave the notes in Reception and they will give them to one of the Consultants who will organise the referral to the TIA clinic Elderly Patients with Minimal Trauma Fractures e.g. fracture pubic ramus, fracture surgical neck of humerus These patients should be assessed to see if they will manage socially with their injury If they will not cope at home they require further input From Monday to Friday from 9am to 8pm they can be referred to the Discharge team – ask the Senior Nurse for this to be done Otherwise they will be referred to the Orthopaedic team on call. They will be admitted under them and the following day they will be assessed by Geriatric team for further rehab needs They do not get referred to the Medical team unless there are specific medical issues – discuss this with the Medical Registrar Patients that have no fracture are referred to the Discharge team during their working hours. If it is out of ours and the patient cannot mobilise then refer to the on call Medical Team. Therapy Services ED has a therapy team to assist with mobility assessments in ED to aid a safe discharge. The service runs seven days and can be contacted by calling vocera and asking for ‘ED Therapy’


APPENDIX 9

Trainee doctors specialty induction checklist KING’S MILL HOSPITAL

Induction for Foundation and Higher Grade Trainee Doctors

Specialty Induction

Si

Name

Grade

Specialty

Start Date (in specialty)

We confirm that the following issues have been discussed at the Specialty Induction meeting and, where appropriate, additional information on accessing further specific details has been shared.

1 Specialty rota and leave arrangements

2 Quality issues

3 Team working/handover

4 Consent

5 Confidentiality

6 Data protection

7 Incident reporting

8 Case note records

9 Bleep policy/fast bleep system

10 Specialty meetings (ie clinical/audit etc)

11 Specialty protocols/guidelines/Medicines Management

12 Trust wide guidelines including How to Raise Concerns Policy, Bulling and Harassment

Policy and Safeguarding Children/Adults/Mental Capacity

13 Death certificate/Coroner reporting

SIGNATURES:

Service Director

[date]

Trainee

[date]

Please photocopy this form when signed (the copy should be kept on the trainee’s record). Return the original form to: Medical Education Postgraduate Co-ordinator, Medical Education Department, King’s Mill Hospital. In the event of a query, please ring extension 3647


APPENDIX 10 - EQUALITY IMPACT ASSESSMENT FORM (EQIA)

Name of service/policy/procedure being reviewed: Induction Policy

New or existing service/policy/procedure: Existing

Date of Assessment:10th March 2018

For the service/policy/procedure and its implementation answer the questions a – c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)

Protected Characteristic

a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups’ experience? For example, are there any known health inequality or access issues to consider?

b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening?

c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality

The area of policy or its implementation being assessed:

Race and Ethnicity

The policy has been designed to ensure equality for all staff when undertaking their induction training


Gender



Age



Religion The policy has been designed to ensure equality for all staff when undertaking their induction training


Disability




Sexuality



Pregnancy and Maternity



Gender Reassignment



Marriage and Civil Partnership



Socio-Economic Factors (i.e. living in a poorer neighbourhood / social deprivation)



What consultation with protected characteristic groups including patient groups have you carried out?

Discussed with and reviewed by Trust Diversity and Inclusivity Lead

What data or information did you use in support of this EqIA?

ESR staff data

As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? No


Level of impact From the information provided above and following EQIA guidance document Guidance on how to complete an EIA (click here), please indicate the perceived level of impact: Low Level of Impact For high or medium levels of impact, please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting.

Name of Responsible Person undertaking this assessment: Lee Radford – Deputy Director of Training, Education and OD

Signature: Lee Radford

Date: 10th March 2018

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