Information Booklet
(Interactive Version)
Version 24 – September 2013
Pages
Section 1 / Induction / 3
Section 2 / Corporate Induction Programme including the Introductory Session / 4
Section 3 / Governance
o Governance Framework
o Risk Management Strategy
o Mental Capacity Act and Deprivation of Liberty Safeguards
o Hospital Policy and Procedure / 5
9
10
11
Section 4 / Workforce Issues
o Corporate Curriculum and Local Induction
o Knowledge and Skills Framework (KSF) and Appraisal
o KSF Appraisal Training
o Trust Values and Behaviours / 12
13
15
16
Section 5 / Safe Environment
o Security Awareness
o Equality and Diversityo Health and Safety
o Medical Devices / 17
20
21
23
Section 6 / Clinical Care
o Patient Journey
o Patient Safety
o Infection Control
o Safeguarding Vulnerable Adults
o Safeguarding Children
o Information Governance
o Health Records Standards
o Palliative Care / 24
26
27
29
30
32
33
35
Section 7 / Learning from Experience
o Incident Reporting
o Complaints Policy and Procedure / 3839
Section 8 / Additional Information
o Hospital Chaplaincy
o Blood Transfusion Training Requirementso Moving and Handling Awareness
o Occupational Health Service
o Workplace Mediation and Harassment Advice
o Harassment Adviser Contact List
o Workplace Mediation Handout
o Workplace Mediators Contact List
o Stress Control Workshops
o Health and Wellbeing
o Trade Union and Staff Side Information
o Fraud Awareness Guide / 40
41
43
46
52
54
56
58
59
61
63
64
Section 9 / Appendices
o Appendix ‘1’ - Mandatory Training Dates 2010/11
o Appendix ‘2’ - Corporate Curriculum (Mandatory and Statutory Compliance Training Delivery) / 66
67
Section 1
Induction
Welcome to Barnsley Hospital NHS Foundation Trust and congratulations on your appointment.
As part of your induction to the Trust, you are required to attend a Corporate Induction programme that lasts 3 days. You will initially attend a Corporate Induction introductory session. This session lasts 2 hours and will cover general Trust information whilst it also includes a Director’s talk.
(To note, if you are a student on a reasonably short Trust placement e.g. 12 weeks this booklet can be accessed instead of attending the face to face Corporate Induction introductory session.)
The rest of the 3 day programme will be a mixture of face to face mandatory and statutory training courses and e-learning. The courses are section 1 courses from the Trust’s Corporate Curriculum.
Once you have completed the Corporate Induction Programme please make use of the Workforce Information Site and the Training Requirements by Position report (all posts are listed by position ID). This report will list all mandatory and statutory training you are required to complete for your role.
The Trust’s Corporate Curriculum document (with 4 sections) will also provide you with further information on courses that are offered by the Trust. This can be accessed from the Learning and Development Department’s homepage.
Finally, your Corporate Induction Information booklet should provide you with information to supplement what is covered in the Corporate Induction 3 day programme and your local departmental induction. Please take time to read this thoroughly and use it as an ongoing source of information during your employment with the Trust.
Thank you
Julie Fellows
Learning and Development Officer
September 2013
Corporate Induction Programme
Aims and Objectives
• To allow new employees and volunteers to meet other new starters and receive a formal welcome to the Trust from a Member of the Board of Directors
• To allow new employees and volunteers to gain an overview of key corporate messages and information
• To signpost new employees and volunteers to how further and more in-depth knowledge and information can be obtained via local induction and the Corporate Curriculum
Programme
08.45 Refreshments
09.00 Introduction and Housekeeping
09.05 Director’s Talk
09.25 Governance and Transformation
09:45 Workforce Issues
10.05 Safe Environment
10:15 Union Talk
10.30 Payroll and Pension
ENSURE PROMPT ATTENDANCE TO ALL TRAINING SESSIONS
Section 3Governance
Governance Framework
Definitions:
Governance
Governance is defined in general terms as’ the systems and processes that exist in order to direct and control activities within an organisation.
Corporate Governance
Corporate governance is defined as, an internal system encompassing policies, processes and people, which serve the needs of the organisation and its stakeholders, by directing and controlling management activities with good business objectivity, accountability and integrity.
Clinical Governance
The most widely used definition of clinical governance is the following:
“A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”.
Governance is about “Getting It Right”, every time.
The main elements of Governance are:
· Comprehensive up to date policies and procedures that are fully embedded within the organisation – All Trust policies are developed in accordance with NHS Litigation Authority (NHSLA) guidelines and can all be accesses through the Trusts policy warehouse portal link on intranet home page or by following this link http://sv sharepoint/systems/pt/default.aspx
· Clinical audit - highlights deficits in adherence with clinical policies and procedures and identify action to improve practice
· Internal and External Auditors – The Trust employs both an internal and external body of auditors in order to monitor the Trusts adherence to its control systems, audits are conducted across a number of areas annually. Clear Audit assessments and improvement recommendations are provided which support assurance to the Board of Directors that the Trust Systematic processes are being delivered as intended
· Staff development - ensures staff have the skills and competencies to deliver the organisational objectives and meet the needs of patients and service commissioners
· Effective Risk Management - recognising potential issues, assessing the risk to the organisation, developing controls and mitigation to manage the identified risk
· Clear processes for organisational learning through
o Analysis of incidents
o External inspections
o Health and Safety issues
o National Patient Safety Agency Data
o Clinical Audit
o Divisional Governance Meetings
· R&D/innovation - improve practice, continually innovate / keep up to date
· Stakeholder Involvement
o Patient/carer involvement - empowers and gives patients/carers ownership
o Clinical Quality / contract review with Commissioners
· Efficient and Effective use of Resources New ways of working - best use of resources, modernisation and ability to embrace change to meet service needs
· Compliance with Standards and Regulatory Frameworks
· Information Governance- meeting the NHS Information Risk Management guidelines
See Governance Mind Map fig 3.1
Assurance is
.
Assurance is provided through to the Governing Council and the Board of Directors, through a number of Board committees and down to divisions and departments. The major committees are highlighted in the following diagram:-
GOVERNING COUNCIL
BOARD OF DIRECTORS
AuditCommittee / Finance Committee / Non Clinical Governance & Risk Committee / Clinical Governance Committee / RATS
Performance Board / Executive Team
Investment
Board / Workforce
Board / Quality Safety Improvement & Effectiveness Board / Patient Experience Board
Divisional Governance Groups / Corporate Working Groups
Infection Prevention and Control, Strategic Risk, Safeguarding Children, Safeguarding Adults, Medical Devices Committee, Falls Steering Group, Radiation Safety Committee, Clinical Guidelines and Policy Group, Medicines Management, Nursing Procedures, VTE Prophylaxis Steering Group, Resuscitation Committee, Organ Donation Committee, Information Governance Group, Complaints Review Group, PPI delivery Group, Outpatient Patient Forum, LNC, Joint Partnership Forum, Equality and Diversity Steering Group, Health and Safety Committee, Change Advisory Group, Medical Gas Committee, Decontamination Strategy Group, Sustainability/Carbon Reduction Group, Emergency Planning and Business Continuity, Medical and Surgical Equipment Committee
Risk Management Strategy
Risk Management is the reduction in harm to an organisation by identifying and, as far as possible, eliminating risk.
Non-clinical risks include threats to business objectives, finance and threats to the hospital reputation, information governance, as well as staff safety and health & safety matters.
Clinical risks include threats to the safety of our patients, quality of care, and service or business interruption.
Each Division or Department regularly analyses Incidents, Complaints, Claims and Coroner’s Inquests and other sources of risk to assess and manage any emerging themes or problems.
There are four strategy areas that support the process of risk management these are:
· Training programmes within the Corporate Curriculum
· Policy and Procedures for risk
· Committee Structures
· Performance Management
Management Arrangements
The Board of Directors has overall responsibility for corporate governance, including risk management. The Board has adopted a framework to its governance arrangements that operates through Board Committees, specifically:
· Clinical Governance Committee
· Non-Clinical Governance Committee
In addition to these there are other Board Committees dealing with:
· Finance
· Audit
· Performance
Within each Division or Directorate a local Risk or Governance Committee will be held, usually monthly, where risk issues will be considered. Depending on your grade you may be involved directly, but all staff are encouraged to contribute to highlighting problems through the local managers or supervisors or by using the incident reporting system.
For new managers likely to be involved in risk management within divisions the following dedicated training is available along with other courses within the Curriculum:
· Risk Awareness for Senior Managers
· Investigation of Incidents and Claims, including Root Cause Analysis
Mental Capacity Act and Deprivation of Liberty Safeguards
Introduction
The Mental Capacity Act partially came into force in April 2007 and will be fully implemented by October 2007. It sets out the legal framework for making decisions on behalf of adults aged 16 years or over who lack capacity to act or make decisions for themselves. The Act affects families and carers, health and social care staff and legal, banking and advice sectors.
The Deprivation of Liberty Safeguards came into force on April 1st 2009. The safeguards provide support for individuals whom as a result of the Mental Capacity Act may have their freedom of movement and other human rights restricted.
What the Act Does Relevant to Health and Social Care
The Act provides a framework for assessing a person’s mental capacity and for determining their best interests if they lack capacity to make a decision. It introduces safeguards and limitations for staff when they are working with someone who lacks the capacity to consent to receiving care or treatment.
In some circumstances Independent Mental Capacity Advocates (IMCA) will be appointed to represent people who lack capacity to make important decisions and have no other person to act as their advocate.
Key Messages
It should be assumed that an adult has the full capacity to make decisions unless it is established that this is not the case.
Individuals should be given appropriate help and support to enable them, where possible, to make their own decisions.
An individual’s participation in any decision making process regarding their mental capacity should be maximised as far as possible.
Those assisting and supporting people who lack capacity should not be overly restrictive or controlling and should always try to find an appropriate balance between a person’s right to autonomy and self determination, whilst ensuring that individuals are safeguarded and protected from harm.
Further Information
Further information in the form of Practice Guidance, can be found on the Trust intranet on the useful documents page.
Hospital Policy and Procedure
Trust policies are available on the Trust intranet site:
· Trust Policy Warehouse - accessed from the A to Z intranet directory under ‘Policy Warehouse’ or click on the icon at the top of the Trust’s intranet home page
· Clinical Policy and Procedure - accessed from the Nursing Procedures intranet pages
· Infection Control Policy and Procedure - accessed from the Infection Control intranet pages
· Be aware of local procedure that relates to your own role and responsibilities
Section 4Workforce Issues
Corporate Curriculum
The Trust has developed a Corporate Curriculum to meet the mandatory and statutory training requirements for staff working in the organisation.
The Corporate Curriculum is aligned to the requirements of the NHS inspection regime and external legislation and in particular the NHS Litigation Authority and Health Care Standards.
Corporate Curriculum
The Corporate Curriculum outlines the category of staff required to undertake a particular development course and the frequency of attendance. The full document (with 4 sections) is accessible on-line from the Learning and Development Department’s intranet homepage.
Dates of mandatory training weeks (offering section 1 courses from the Corporate Curriculum) are listed in Appendix 1 whilst Appendix 2 lists all mandatory and statutory training being offered during these weeks.
For information, a range of training courses can be booked by contacting the Education Centre’s Admin Team on extension 2553. These can also be booked on-line through the Learning and Development Department’s intranet page. If the course you are interested in is not booked by the Learning and Development Department the Admin Team will be able to direct you to the correct person.
Local Induction Checklist
To enable a comprehensive introduction to the organisation to be successful, the management of local induction is the responsibility of your immediate line
manager.
To ensure a structured approach to local induction, the local induction checklist must be completed within the timescales set for each section and returned to the Learning and Development Department within 2 weeks of commencement within post for permanent employees and within 1 week for temporary employees.
Please note a copy of the induction checklist (for permanent and temporary employees) will be forwarded to all new starters with the new starter pack sent out by the HR Department. Line managers will also receive a copy of the checklist from the HR Department.
To note all checklists can be downloaded from the Learning and Development intranet pages under Local Induction.
Simplified Knowledge and Skills Framework (KSF) and Appraisal
The KSF is an NHS wide framework that can be used consistently across the service to support:
o personal development in post