Download Knowledge Gap Internal Briefing Full

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STAFF BRIEFING
An overview of essential processes and policies
This document contains
1) An overview of the key points within essential processes and policies
2) Useful contacts for each area
3) Signposts to additional policy information on the intranet
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Question 1 : Are we safe?
Mental Capacity Act
Independent Mental Capacity Advocates
Safeguarding Adults
Safeguarding Children
Infection Control
Cleanliness
Medicine Safety
Monitoring Drug Fridge Temperatures
Health and Safety
Waste Management
Medical Equipment
Safe Staffing
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Mental Capacity Act
Summary
• The Mental Capacity Act applies to everyone who works with people who lack
capacity
• Provides a statutory framework to empower & protect people who may lack capacity
to make some decisions for themselves (e.g. dementia, learning disabilities, mental
health, stroke/head injuries)
• Enables them as far as possible to make appropriate decisions on their own behalf
• Protects the rights of those who make decisions on their behalf (health workers and
care workers)
• It’s purpose is to provide clarity and safeguards around the research in relation to
those who lack capacity
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Mental Capacity Act
Five core principles
• All decisions about mental capacity should be guided by five core principles:
• Assume a person has capacity unless otherwise indicated
• All practicable steps must be taken to help person make a decision
• A person is not to be treated as unable to make a decision merely because it is an
unwise decision
• Any act/decision taken on behalf of someone must be in their best interest
• Always consider the least restrictive option/intervention.
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Mental Capacity Act
The Act clarifies…
• What “lack of capacity” is:
• A person lacks capacity in relation to a matter if at the material time he/she is
unable to make a decision for himself in relation to the matter because of an
impairment of the mind
• The impairment may be temporary or permanent
• How to assess capacity:
• Assume a person has capacity unless otherwise indicated i.e. start from a
presumption of capacity then take into account the person’s behaviour, their
circumstances and any concerns raised by others
• Assessment of capacity should be specific to the decision to be made at a
particular time
• Avoid assumptions by reference to age or appearance, or aspects of behaviour
which could lead to unjustified assumptions
• Staff always document and keep records of any assessment.
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Mental Capacity Act
• Assessment of a person’s capacity must consider the following factors:
• Can they understand the information
• Are they able to retain the information
• Are they able to use or weigh that information as part of the decision making
process
• Can they then communicate their decision
• Who assesses capacity?
• The person delivering the care or treatment is responsible for assessing capacity
in relation to the care or treatment proposed - this includes healthcare staff,
social care staff, family, unpaid carers.
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Mental Capacity Act
Best interests
• Where a patient has been assessed as lacking capacity to make a particular decision,
the decision-maker has to act in the patient’s “best interests”
• The Act does not define “best interests” but provides a checklist – detailed on the next
slide
• There is a duty under the Act to consult with the carer, interested party, persons
holding powers of attorney, etc. before a best interest decision is made
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Mental Capacity Act
Best interests checklist
• Avoid assumptions about the patient’s best interests merely on the basis of age,
appearance, condition or behaviour
• Consider a patient’s own wishes, feelings, beliefs & values and written statements
made when they had capacity
• Take account of views of family and carers or Independent Mental Capacity Caldicott
(See IMCA slides)
• Can the decision be put off until the patient regains capacity?
• Demonstrate that you have carefully assessed any conflicting evidence or views
• Provide clear, objective reasons as to why you are acting in the patient’s best interests
• Take the less restrictive alternative or intervention.
For more information contact safeguarding lead David Flood on ext 1624 (Bleep: 8031)
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Independent mental capacity advocates
(IMCA)
• There is a legal duty for an Independent mental capacity advocates (IMCA) to be
instructed where:
• There is a decision to be made regarding SMT or accommodation
• The person has been deemed not to have capacity to make that decision
• The person has no close family or friends who are appropriate or practical to
consult
• Urgent decisions (“life or limb”) should not be delayed.
• The IMCA does not:
• Assess capacity
• Make the best interest decision
• Mediate between family and professionals
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Independent mental capacity advocates
Free service – St George’s uses Voiceability - Hotline - 0845 0175 198
What do IMCAs do?
• Represent and support the person in relation to their “best interests”
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Find out the views, feelings and beliefs of the person.
Make sure that the person can participate in the decision-making process
Obtain & evaluate information
Look at other courses of action
Consider seeking a further medical opinion if necessary
• Check the Mental Capacity Act principles and best interests process are being
followed
• Prepare a report, which the decision-maker has a legal duty to consider.
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Safeguarding Adults
Everyone’s responsibility
All staff should:
• Be able to recognise abuse and neglect
• Know what action to take if they have a concern about an adult
• Know where and from whom to access support and advice
• Know how to access the safeguarding adults site on the intranet (documentation,
information, training)
• Be confident about information sharing
• Understand that they have a duty to report concerns.
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Safeguarding Adults
It’s your responsibility
What to do if you have a concern? – Five Rs
• Recognise signs or symptoms of abuse or neglect
• Respond - Listen and reassure - Think safety first
• Report – Datix and inform your line manager
• Record and document evidence
• Refer to safeguarding lead/social services
Please do not ignore the situation.
Safeguarding adult lead is David Flood - ext 1624 (Bleep: 8031)
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Safeguarding Adults
Signs / symptoms
• Unexplained injuries – bruises, fractures or burns
• Think history – Any inconsistencies? Unusual sites?
• Behaviour – passive, stressed/agitated, check with family/carers (if appropriate)
• Neglect – malnutrition, pressure ulcers, isolation, home environment, hygiene, access to
services
• Financial – basic needs not being met, unpaid bills
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Safeguarding Children
Everyone’s responsibility
All staff should:
• Be able to recognise abuse and neglect
• Know what action to take if they have a concern about a child or young person (under
18 years)
• Know what action to take if they have concerns about an adult who is a parent or carer
• Know where and from whom to access support and advice
• Know how to access the safeguarding children section on the intranet (documentation,
information, training)
• Be confident about information sharing
• Understand that they have a duty to report concerns.
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Safeguarding Children
Recognition of abuse and neglect
Physical abuse
• Bruises, burns, fractures, - does the injury fit the history and the child’s
developmental stage?
Neglect
• The persistent concerns...
• Unkempt, dirty, hungry, inappropriate clothing, DNA’s, untreated medical conditions,
poor school attendance, developmental delay...
Emotional abuse
• Withdrawn, behavioural issues, low self esteem, soiling, wetting, parents who are
negative/critical
• Includes impact of domestic abuse
Sexual abuse
• Sexualised behaviour, language, soiling, wetting, physical signs
• Sexual exploitation.
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Safeguarding children
Be aware
• The adult issues that may present concerns for
children in their care and what to do
• Domestic violence, drugs and alcohol, mental health
issues, chronic health issues, learning disability,
criminal behaviour all increase the risk to children
• The level of training you require, depends on how
often you are in contact with children
• Have access to key documents – available via the
intranet under procedural documents
• How to contact social services
• A critical policy for paediatric staff to understand
`
People who can help:
• Dr Sarah Thurlbeck
x3648 (named Dr)
•Geraldine Fraher x 5237
(named nurse acute
paediatrics)
•Caroline Beazley
(named nurse)
•Marion Louki x0700
(named midwife)
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Infection Prevention and Control
Single-use items
• Single-use items should be used once and discarded. Do not re-use single items
• Discard all other unused items in a pack e.g. mouth care packs and NG syringes
• Look for this symbol on packaging for single-use items
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Infection Prevention and Control
Re-usable items
Re-usable items must be adequately reprocessed between each patient
There are three levels of decontamination
• Cleaning
• physical removal (blood, faeces, etc) and many micro-organisms with detergent
• mattresses, bedside lockers
• Disinfection
• reduces the number of micro-organisms to a safe level, spores are not usually
destroyed
• endoscopes, bedpans, commodes, crockery
• Sterilisation
• removes or destroys all micro-organisms, including spores
• surgical instruments
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Infection Prevention and Control
Further inspection
• The Infection Control Manual and infection control pages are available on the intranet
• The Infection Control Nurses are available
• Monday to Friday 08:30 to 17:30 via Bleep 6798
• Office 08:30 - 16:30: ext. 2459
• For urgent calls out of these hours please contact the on-call microbiologist via the
switchboard
• Each ward has in infection control notice board – is your board up to date?
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Infection Prevention and Control
Keeping clean and clutter free
• Ensure the Know your Responsibilities – posters are displayed on the wards to inform all who does what
for cleaning- including how often areas are cleaned.
• Ensure you know to contact the helpdesk and how to report cleaning and estates concerns and how to
escalate.
• Ext 4444 (4438/7 out of hours) for Estates and Cleaning in Atkinson Morley Wing
• Ext 4000 (bleep 7888 out of hours) for all patient’s meals across all areas and ext 4000 for all cleaning
across the rest of the Trust (SGH) (bleep 7888 out of hours)
• Ext 1234 Trust estates team (all non AMW areas at SGH) bleep 6407 emergency engineer bleep out of
hours.
• Do you know who your cleaning supervisor is / the names of your cleaning team on the area? If not find
out
• Ensure you have your latest cleaning audits up on the Infection Control notice board. Did your staff
accompany the audit team and sign off the audit ?
• Remember to check the bed area once a deep clean has been completed to ensure that this is
satisfactory before the next admission and that this has been noted.
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Infection Prevention and Control
Caring for the environment top tips
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Cleanliness
NHS Standards and responsibilities
• Current standards 2007 National Standards – 49 elements and 2009 NHS
Cleaning Manual
• Specific Risk Categories depending on levels of infection e.g. Wards - High
risk
• The higher the risk the more frequent the cleaning and the more frequent
the auditing
• Nursing /cleaning staff areas of responsibility
• Duties outlined in SLA/posters in ward areas
• Infectious cleans guidance on intranet
• Cleaning of Body Fluids
• See Infection Control policies
• Use neat Milton or Haztabs
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Caring for the Environment - Top Tips
• Have your staff had waste management training ? Ensure that all staff understand the
different types of waste and ensure that this is being carried out correctly.
• Remember to look up as well as down when reviewing your environment.
• Ensure staff have been trained on how to clean equipment – drip stands, commodes, BP
machines, resus trolleys, raised seats, clinical storage racks, pc’s keyboards and screens,
mattresses, body fluids.
• Linen – ensure that this area is separate from other items and that it is clean and tidy –
always reject linen if not up to standard.
• Are all gel/soap dispensers/toilet paper/hand towels/aprons full all the time ?
• Curtains are changed every 6 months in addition to the changing of these after patients
have left the Trust. These records are kept with the cleaning teams.
• Further support can be given by contacting the Facilities teams via ext 1234 or on bleeps
7159 / 7664 or on ext 0058.
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National colour coding scheme for hospital cleaning
materials and equipment
• All NHS organisations should
adopt the colour code (right) for
cleaning materials.
• All cleaning items, for example,
cloths, (reusable and disposable)
mops, buckets, aprons and gloves
should be colour coded.
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Medicine Safety
• Ensure you have read and understood the relevant sections of the medicines policy
and know how to access it
• Never administer anything you are not confident about or assessed as competent to
do. If not sure speak to your named pharmacist
• Never give any medicine (or undertake any procedure) without confirming the
patient’s identity
• Ensure all medicines are always locked away and not left on lockers or in the open
• Ensure all cupboards, fridges, PODs and trolleys are locked and the keys are with a
registered nurse or midwife
• Do not administer and leave medicines with patients to take later, this must be
observed (may be different for some in offender healthcare)
• Ensure that if any medicines are omitted this is documented clearly with reasons
• Ensure you attend all regular updates and relevant training
• Please ensure you report and record all near misses or errors on Datix and tell your
manager
• Make sure allergies are clearly documented on prescription charts
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Monitoring Drug and Fridge Temperatures
Previous CQC inspection highlighted drug and fridge temperatures as a risk
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CQC said - “Patients were not protected against the risks associated with medicines because the
temperatures of medicines storage areas on some wards were not monitored consistently.”
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Key points
– Ensure all drug fridges must have a calibrated thermometer to monitor minimum and maximum
temperatures
– Clinical areas must use the trust approved temperature monitoring log form
– Drug fridges must be monitored on a daily basis
– Any deviation in drug fridge temperature must be acted upon, following the temperature
deviation procedure
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Since August 2013, a Trust-wide Drug Fridge Thermometer Calibration Service has been rolled out
– Calibrated thermometers have been purchased and installed in clinical areas for monitoring of
minimum and maximum temperatures
– Policies are available on the intranet, Pharmacy Department page, for drug fridge temperature
monitoring, temperature deviation and for defrosting drug fridges. See link:
http://stginet/Units%20and%http://stginet/Units%20and%20Departments/Pharmacy/Fridge%20
Monitoring.aspx
– Key clinical staff have been trained on the fridge thermometer calibration process and monitoring
requirements.
For further training please contact [email protected] or [email protected]
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Health and Safety
Managing health and safety and risk assessments
A Risk Assessment – The process of identifying risks to and from an activity and assessing the
potential impact of each risk (CQC Guidance Essential standards of Quality and Safety 2009)
• The Management of Health and Safety at Work Regulations (1999) state:
• Every employer shall make a suitable and sufficient assessment of the risks to the health
and safety of employees to which they are exposed to at work (staff, volunteers)
• The risks to the health and safety of people not in their employment (Patients, Visitors etc)
• Only trained and competent people should carry out a risk assessment, for training or guidance
please refer to the Risk management policy or contact:
• The risk management department ext 4054 or 4966 or The Health and Safety department
ext 3309 or 4043
• Examples of patient specific risk assessments: VTE, SBAR, EWS, pressure ulcers and falls
• Examples of non-patient specific risk assessments: manual handling, fire, emergency evacuation,
environmental.
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Health and Safety
How to carry out a risk assessment
• Identify the hazards - consider human, environmental and emergency factors
• Consider who may be harmed and how - consider patients, staff, visitors and anyone
else who may be in the area. Also consider personal factors like age, medication,
medical conditions
• Evaluate the risks and decide on risk control measures - Use the relevant risk scoring
matrix to score the risk and decide on the control measures required to reduce the risk
to an acceptable level
• Record the findings - To demonstrate that the assessment has been carried out and to
instruct other members of staff on the required control measures
• Review and update - risk assessments must be reviewed at time intervals relevant to
the assessment. If anything changes in regards to the patient, the control measures
required or the environment, then this must be recorded in the risk assessment.
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Waste Management
Correct waste segregation
Infectious clinical waste
Domestic waste
Clinical waste for incineration
Recycling
Sharps bins in caddies
with lids of same colour
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Waste Management
Correct waste segregation
Pedal bins
The pedal bins used in clinical areas should be
rust-free and clean. Silent-closing, rigid body bins
can be obtained from EHP via Agresso. For 70 litre
rigid body bins the product code is HSBM1030SC,
when ordering please state colour required. For the
disposal of old bins please contact Waste Manager.
For further advice contact the
Waste Manager on x3169
Clinical Waste
Sharps bins
Sharps bins should:
1. Have the lid firmly attached
2. Not be filled above the line
3. Not to be used when ¾ full
4. Have the label completed to show where and when used
5. Contain only sharp objects, which should be placed into a
sharps bin as soon as they have been used
6. Always be mounted on a bracket, available from Waste
Manager, or in POUD tray.
Domestic Waste
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Medical Equipment
• Medical Equipment must be:
• Safe: Properly maintained and used correctly
• Suitable for its purpose
• Available
• Support is from Medical Physics and Clinical Engineering Department
Practice Nurse Educators and the Procurement Department
• Policies
• Medical Devices Management and Use policy
• Medical Devices Training Policy
• Procurement policy
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Medical Equipment
• Only use equipment you are competent to use. Request training as required
• Only use equipment that you are sure is fit for the purpose (that is, the correct
equipment and accessories to perform the task)
• Ensure any equipment checks required are carried out
• Report any faults or concerns about equipment function to Medical Physics, and take
equipment out of use
• Report any safety incident involving equipment, and take the equipment out of use (&
save all consumables for investigation).
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Medical Equipment
• Only use ‘Know how’ to borrow from the equipment library
• Return equipment to the equipment library when finished with – someone else will
need it
• ‘Know how’ to request pressure relieving mattresses including out of hours.
• Assess and return pressure relieving mattresses not required – someone else needs
one
• Assess whether any lack of equipment is detrimental to patient outcomes. Make
senior staff aware of any lack. Budget holders to manage locally bought equipment,
and to present capital equipment requests to their division
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Safe staffing
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The Trust has a duty to ensure staffing levels are sufficient to maintain safety,
minimise risks to patients and provide quality care. Nurse staffing levels make a
difference to patient outcomes, patient experience, quality of care and the
efficiency of care delivery (all staff should read the safe staffing policy).
We should work towards having the right staff with the right skills in the right
place at the right time with the right leadership.
Safe staffing can be defined as whether staff can safely:
• Complete vital signs observations - (especially post-operatively, and 1:1 ‘specials’)
• Assist patients with nutrition
• Assist patients with hydration (drinks and intravenous or nasogastric fluids)
• Care for pressure areas
• Administer drugs and and oxygen therapy
• Take their statutory rest breaks
• Complete risk assessments for new patients including PUP and MUST.
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Safe Staffing – top 10 tips
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Each unit, ward, department and community service will have an agreed number of
Nurses, Midwives and Health Care Assistants for each shift of the 24-hour day – ensure
you know what these numbers are.
The duty roster should be planned in advance with the aim to provide the best possible
nursing skill mix
Safe staffing relies on good management of your rota. Ensure that all permanent staff
hours are used. Ensure everyone on short or long term sickness is managed with the aim
of getting them back to work as quickly as possible
Gaps in the nursing numbers due to vacancy or sickness may be covered by bank staff or
agency staff (refer to your locally agreed procedure for authorisation)
Assess your patient acuity/dependency at handover and ensure you have sufficient staff
to cover the required work for the shift. Review your skill mix and ensure staff are
allocated appropriately to cover the nursing workload
If you have a concern, talk to your Matron / Head of Nursing. If they are unable to assist,
ensure your Divisional Director of Nursing (DDNG) is contacted. They are expected to
liaise with other senior staff in the organisation to provide a solution
Be clear about what you can and cannot do. Have precise information on staff numbers,
skill mix, patient dependency and the definition of safe staffing (above) to support your
case for more staff or other interventions (eg. Stopping admissions or transfers for two
hours). Be clear about what you could stop and for how long (eg. Escorts).
Once your concerns have been highlighted and acted upon, record your staffing situation
before 10am using the real time RaTE system.
Remember that any change to staffing or dependency can affect staffing for the following
24 hour period. Ensure a plan is in place to respond to this.
DO NOT BE AFRAID TO CHALLENGE IF YOUR WARD IS UNSAFE
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Question 2 : Are they effective?
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Consent
Information Governance
Records Management
Documentation
Accessing Policies
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Consent
• Patients have a fundamental legal and ethical right to determine what happens to their
own bodies. Valid consent to treatment is therefore absolutely central in all forms of
healthcare
• Consent is a patient’s agreement for a health professional to provide care. Consent can
be given expressly i.e. in writing or orally, or may be implied e.g.. when a patient
presents his arm for blood or pulse to be taken
• Valid consent: For the consent to be valid, the patient must:
• have capacity to consent (see slides on the Mental Capacity Act in the safety
section)
• have received sufficient information about treatment options, consequences and
risks; and
• not be acting under influence of others
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Consent
Documentation
• It is rarely a legal requirement to seek written consent, but it is good practice to do so for all significant
procedures eg. where the treatment/procedure is complex or involves significant risks (‘risk’ may refer to
adverse outcome, including ‘side-effects’ or ‘complications’), or where the procedure involves general
anaesthetic or sedation
• For such procedures, it is essential to document clearly both a patient’s agreement to the intervention and the
discussions which led up to that agreement; and also the type and version control of the information leaflets
that are given to the patient.
• This may be done either through the use of a consent form or through documenting in the patient’s notes that
they have given oral consent.
• Consent is often wrongly equated with a patient’s signature on a consent form. A signature on a form is
evidence that the patient has given consent, but is not proof of valid consent.
• Patients may withdraw consent at any time – a signature on a consent form is not a binding contract!
• Completed forms should be kept with the patient’s notes.
• It is not usually necessary to document a patient’s consent to routine and low risk procedures, such as providing
personal care or taking a blood sample unless there is reason to believe that the consent may be disputed later.
• It is always good practice to check that a patient is happy for you to give them treatment before you start.
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Consent
Capacity
• Valid consent can only be given by someone with the mental capacity to be able to consent.
• Adults (18+) - are presumed to have capacity to consent, unless the contrary is shown
• 16 / 17 year olds - For the purpose of consenting to treatment, minors aged 16 and 17 are treated
as adults (but their refusal is not binding, and can be overriden by someone with parental
responsibility)
• Children under 16 - can give consent if they have sufficient understanding and intelligence – i.e.
Gillick competent (but they cannot refuse treatment). They must be able to understand fully the
intervention proposed and the consequences. Healthcare professionals should always encourage
the child to inform those with parental responsibility.
• Where a child is not Gillick competent, consent may be obtained from someone with parental
responsibility.
• Patients who lack capacity - the Mental Capacity Act 2005 governs decision-making on behalf of
patients (16+) who lack the mental capacity (either temporarily or permanently) to give or
withhold consent for themselves. (see slides on the Mental Capacity Act in the safety section)
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Information Governance
What is Information Governance?
• Information Governance is a complicated way of saying: “anything you do with information”
• i.e. creating, using and ultimately destroying or archiving information - securely, legally and
efficiently.
• or more formally:
• “The management of all information from creation to destruction”
What is “personal data”?
• The formal definition of personal data is: “Data which relates to a living individual who can
be identified from the data or from that data and other information which is likely to
become available.”
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So any information that can identify an individual e.g. name, NHS number, hospital number,
staff number, address etc., is personal data. You also have to be careful with combinations
of data e.g. address and date of birth – this data could possibly identify an individual at an
address.
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Information Governance
• Patients trust us to keep their information safe and that trust is vital for us to provide a safe and
caring service
• You can share patient data with staff who have a direct involvement with the patient’s care
• If you have the patient’s consent then you can share with other people, but the patient must
understand the implications of this sharing and have the option to stop the sharing at any point
• Never be bullied into releasing information, no matter how “important” the person asking for the
information is
• If you don’t feel confident about sharing, or not sharing, information, always check with senior
staff or the Information Governance manager on ext 3404
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Information Governance
Caldicott Guardian
• Every trust has a board level Caldicott Guardian responsible for information confidentiality, ours is
the Medical Director Dr Ros Given Wilson (ext 2958).
• Every trust also has a SIRO (Senior Information Risk Owner) .The SIRO is responsible for the risk to
all information in the Trust – our SIRO is the Director of Finance, Performance & Informatics Steve
Bolam (ext 4747)
• The Caldicott Principles: A set of basic rules on what to think about when using confidential
information
• Justify the purpose(s)
• Don’t use personal confidential data unless it is absolutely necessary
• Use the minimum necessary personal confidential data
• Access to personal confidential data should be on a strict need-to-know basis
• Everyone with access to personal confidential data should be aware of their responsibilities
• Comply with the law
• The duty to share information can be as important as the duty to protect patient
confidentiality.
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Documentation - top 10 tips
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Confidentiality – medical notes are ideally kept in a locked cabinet. If notes are not in a locked cabinet,
they should be kept in a cabinet in a locked room or somewhere they can be observed.
Do not leave records on paper or computer screens where they might be seen by unauthorised staff or
members of the public.
Smartcards or passwords to access information must not be shared.
All patients must have a care plan - pre printed care plans are acceptable as long as they are individualised
–which they have seen, consented to and signed. Care plans must be regularly reviewed and there should
be documented evidence that this has occurred.
Ensure all relevant nursing documentation is organised and included in the patients file and is completed
accurately. This includes such variety as next of kin details, allergies recorded on the medication chart and
evidence that all risk assessments have been completed on admission and updated on a weekly basis or if
the patient’s condition changes.
Observations should be taken as required throughout the 24 hour period and an accurate early warning
score should be clearly recorded (all staff to ensure they read the policy). If you wish to raise a concern to
another professional use the SBAR guide (situation, background, assessment and recommendation) to
structure your conversation.
All entries to records should be signed – Name, job title, date and time should be recorded. Handwriting
should be legible.
Good record keeping is an effective communication tool. During any handover, staff should be able to
understand what has happened to a patient / group of patients and have adequate information to plan
their nursing activity for the rest of the day.
Do not include unnecessary abbreviations, jargon, or speculation. Identify the care delivered, potential
risks or problems and show the actions taken to deal with them.
Do not amend records without signing and dating the amendment.
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Documentation
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Good record keeping is an integral part of practice and is essential to the
provision of safe and effective care.
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It has many important functions including a range of clinical,
administrative and educational uses which include helping to improve
accountability, showing how decisions relating to patient care were made.
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It helps to identify risks in order to enable early detection of complications
and provides documentary evidence of services delivered.
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You must record your work clearly, accurately and legibly at the same
time as the events you are recording as soon as possible afterwards.
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Clinical records should include relevant clinical findings, the decisions
made, the information given to patients and any drugs prescribed or any
other investigation or treatment
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Records Management
• The trust and our patients rely on accurate and up to date records.
• Always check the identity of the patient matches the record. If the patient is present always ask
the patient to confirm their details. The correct way to ask is e.g. "Could you tell me your address
please" not "Do you still live at……". The patient should give you the information, not the other
way round.
• If searching for a patient on Cerner Millennium or RIO be absolutely certain that you have
correctly searched the PDS [the national spine] not just the local record. The Spine holds the most
recent and accurate patient demographics. The local record could be years out of date.
• Make sure you track the patient records on the system to where you have taken them.
• Keep hardcopy records in a safe place. Make sure they cannot be accessed by anyone who does
not have the right to see them.
• Don’t leave medical records lying about, always return them to the notes trolley (which should
ideally be locked away or at least in a place where it is under constant observation)
• If sensitive hardcopy information needs to be destroyed, always use the trust’s confidential waste
bags [blue] or shredders – before destroying records always check with your manger about record
retention rules.
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Records management
“You are your password”
• Remember the computer systems think the password is you; anything done on your password or
smartcard will be traced back to you.
• Always log out of a computer or application when you’ve finished with it – so that the next user
cannot use your access rights or access your patients’ records.
• Never share your password or smartcard with anyone.
• If you suspect that someone knows your password, change it immediately.
• Any trust computer hardware must be disposed of through the IT dept.
• Never use your own computer equipment [tablets, phones, laptops, home computers] to store
patient data [words or images] unless you have checked with the IG manager first.
• All data on Trust systems belongs to the Trust and will be accessed by the Trust if there is a
business reason to do so.
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Accessing policies
All policy documents are available via the intranet
They can be accessed via the homepage by selecting Procedural Documents
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Accessing policies
Policies are divided in to five key areas
• Patient related
• Staff related
• Corporate and IT
• Major incident
• Health and Safety
• Community Services
For more information contact the corporate affairs manager on ext 4699 – check job title – think its Ext 1158
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Question 3 : Are they caring?
Equality and diversity
Interpreting services
Complaints
Communication effectively with patients
End of life care and DNACPR
Friends and Family
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Equality and Diversity
What is equality and diversity?
• Equality and diversity is a term used to define and champion equality, diversity and
human rights as defining values of society. It promotes equality of opportunity for all,
giving every individual the chance to achieve their potential, free from prejudice and
discrimination.
• Direct discrimination is when one person receives less favourable treatment than
another person because of a protected characteristic.
What training is provided by the trust?
• E&D is part of the new starter induction programme
• It is also part of the MAST programme, covering:
• Equality Act - protected characteristics, EDS and public sector duty
• Differences between equality and diversity
• Prejudice, stereotyping, unconscious bias
• Institutational discrimination
• Benefits of E&D to the organisation, staff, patients/visitors
• Local policy and procedures, including bullying and harassment
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Equality and Diversity
What are the statutory requirements?
• The Equality Act 2010 came into force in May 2012
• All NHS organisations are required to make sure health and social care services are
fair and meet the needs of everyone, whatever their background or circumstances.
• The Equality Act 2010 offers protection to nine characteristics. These are:
• age
• race
• sex
• gender reassignment status
• disability
• religion or belief
• sexual orientation
• marriage and civil partnership status
• pregnancy and maternity
• The law also protects people who are at risk of discrimination by association or
perception. For example, a carer who looks after a disabled person.
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Equality and Diversity
How do I demonstrate equality and diversity in care?
For example…
• Does the patient understand?
• Interpreting services available for inpatient or outpatient consultations (either
face to face or by telephone)
• Is the interpreting services poster clearly displayed?
• Are patients’ needs catered for?
• Catering for nutritional needs - special menu available where necessary
• Red trays for those that need help and red tumblers and jugs for those who
would need help with fluids
• Multi-faith chaplains available
• Respecting specific wishes as part of care plan (e.g. Jehovah’s witnesses)
How do I find out more?
• Trust lead for equality and diversity – Wilfred Carneiro Ext 4175
• Within divisions, the Governance Manager will be able to offer guidance
• Trust intranet contains key policies, e.g. HR policy – Equality and Diversity in
Employment
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Interpreting and signing guidance
• Whenever possible we should not rely solely on, or expect family members or
staff to interpret or sign for patients. (In an emergency this may be necessary).
There are different types of support available, some that need to be booked in
advance and some that are available 24/7.
• If you have any queries, please contact PALS or visit their intranet site. Out of
hours please contact the site management team.
The support that is available is:
•Face to face interpreting (foreign language)
•Telephone interpreting (foreign language)
•British sign language
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Interpreting and signing guidance
Face to face interpreting services
• Is not available out of hours and must be booked in advance. A minimum of three
days notice is required.
• Face to face interpreting services are provided by Central and North West London
NHS Foundation Trust Interpreting Service. To book, fill in the booking form
available on the PALS intranet site
• Email the booking form to [email protected] or fax to 020 3317 2940
Telephone interpreting service
• Is available 24 hours a day and can be used in an emergency
• Is provided by Language Line telephone interpreting service
• Staff should locate their department ID on the PALS intranet page and call
0845 310 9900. Full instructions are provided on the intranet.
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Interpreting and signing guidance
British Sign Language (BSL)
•
•
•
•
•
Please note that the British Sign Language service should be booked in advance.
However there is an emergency service available from the Royal Association for
Deaf People (RAD) which can be accessed by calling 07974325563.
There are a number of providers you can access. However the RAD is our
preferred supplier.
The booking form and further information is available on the PALS intranet site.
Please note all BSL interpreting services will need to be paid for direct from your
departmental budget.
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Complaints
• We must always try to resolve someone’s concerns at the time. Referring them to
PALS or to make a complaint straight away is not always helpful.
• If you don’t feel confident to resolve an issue find a senior colleague
• If someone does want to speak to a more senior person try to contact that person for
them rather than just giving them a number, and document concerns
• If you respond to complaints please offer a local resolution meeting, not all replies
have to be via letters
• Say sorry if someone is upset (even if not your “fault”), it is not an admission of guilt
and usually is all that someone wants to hear
• Don’t take it personally or get defensive, someone may be just upset but not with
you
• If you know someone is cross or upset don’t avoid them, it will make things worse
• If you are concerned something may be a serious incident ensure it is reported on
Datix and tell your manager and document it
• If there are serious concerns about care/neglect/abuse contact the Matron/Senior
Nurse or Midwife and the Safeguarding Lead David Flood on bleep 8031
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Communicating effectively with patients
• Always seek permission and explain what you are doing
• Don’t assume that the patient understands – encourage them to ask any questions
• Provide leaflets or written information if it would be helpful
• Involve the person at every opportunity – explain what the plan of care is and ensure
that they are in agreement
• Keep patients, relatives and carers updated as appropriate, even if nothing new, let
them know.
• Don’t talk over or about patients in their earshot, even if they are unconscious or
confused
• Remember intentional/comfort rounds if appropriate. Tell the patient when you will
be coming back so they are reassured and don’t have to rely on their call bell or
telephone if at home
• Document conversations with the patient and any preferences or plans they have
• Remember to ask the patient to complete the FFT and RaTE surveys for feedback
• If patients need an interpreter or signer contact PALS on ext 2453 or if outside 020
8725 2453 and for an IMCA the Safeguarding Lead Nurse David Flood on bleep 8031
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Palliative and end of life care
Palliative care
Palliative care is the active holistic care of patients with advanced progressive illness. It affirms
life and regards dying as a normal process.
• Involves management of pain and other symptoms
• Provides psychological support for patients and families to help cope during the patients
illness and their own bereavement.
• Provides social support
• Provides spiritual support
• Neither hastens nor postpones death
“The goal of palliative care is achievement of the best quality of life for patients and their
families” (NICE)
End of Life Care
End of Life Care is a term interchangeable with Palliative Care and can refer to care given at any
time between the last year and last days of life. An ‘End of Life Care Plan’ specifically refers to
care in the last hours to days of life.
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Palliative and end of life care
The Palliative Care Team at St. George’s is a multidisciplinary team of Doctors, Clinical Nurse
Specialists and a Counsellor.
•The team provides:
• Advice and support for any in-patients with life limiting illness
• Symptom control
• End of life care (last hours/days)
• Rapid discharge home project (fast track service)
• Regular teaching for Trust staff and undergraduate students
•The team is available for face to face visiting 7 days a week 9am to 5pm
• Outside of these hours telephone advice is available from the on call Registrar at Trinity Hospice
via 0207 787 1000
•Referrals should be made by bleeping the referral bleep 6508. Urgent referrals seen within 24hrs.
•The Palliative Care Team Intranet Homepage contains links to:
• McKinley Syringe Pump Policy
• Care in the last days of life guidance
• Education links
• Rapid discharge guidance
• Team contact details
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Care in the last hours and days of life
• All patients who are identified by the Senior Clinician in charge of their care as
being in the last hours or days of life should be referred to the palliative care
team and have an individual end of life care plan.
• The Principles of ‘Care for Dying Patients’ and ‘Daily End of Life Care Guide’ are
available via the palliative care homepage on the intranet. The following
principles are detailed.
• Communicate
• Document
• Review interventions and medications
• Maintain excellent basic care
• Assess symptoms regularly
• Identify support needs of family
• Identify spiritual needs
• Care after death
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Do Not Attempt Cardio Pulmonary
Resuscitation ( DNACPR)
• Cardiopulmonary resuscitation (CPR) is a treatment that could be
attempted on any individual in whom cardiac or respiratory function ceases.
• It is essential to identify patients for whom cardio-pulmonary arrest
represents the terminal event in their illness and for whom CPR will not work
and / or is inappropriate.
• It is also essential to identify those patients who would not want CPR. If a
patient with capacity refuses CPR or has a valid and applicable advance
decision refusing CPR, this should be respected
DNACPR decisions apply only to CPR and not to any other aspects of
treatment
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DNACPR Process
•
•
•
•
•
•
The responsibility for DNACPR decision-making rests with the most senior clinician, It is
recommended that these decisions should not be made in isolation, but where
appropriate, should involve the patient (or those close to the patient if s/he lacks
capacity) and others involved in the clinical care of the patient.
When planning the care of the patient, a decision should be made with regards to
whether the patient would benefit from CPR should they suffer a cardiac arrest. Ideally,
this should be done on admission and be reviewed if there is a significant change in the
patient’s medical condition. ( the decision making framework is available in the Trust’s
DNACPR policy, page 6)
If the decision is to not attempt resuscitation, this should be documented clearly using
the trust’s DNACPR form which is then filed at the front of the patient’s medical notes.
Teamwork and good communication are of paramount importance. It is fundamental
that any DNACPR decision is communicated to all members of the multidisciplinary
team involved in the patient’s care
DNACPR decisions must be reviewed regularly and especially where there is a change in
the patient’s condition or in the patient’s expressed wishes.
At St George’s, DNACPR compliance is audited and reported on annually as part of the
Trust’s risk management strategy
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Friends and Family Test (FFT)
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•
•
•
•
•
•
•
•
Encourage patients to complete the Friends and Family Test
Ask on discharge from care
The survey asks patients - How likely are you to recommend us?
Average 1,200 surveys a month
Tablets, kiosks and paper (RaTE system)
A&E, wards and now Maternity
Minimum number of surveys required 15%
The score can range from -100 to +100
We report every month and on public website
Interpreting results
•
•
•
•
•
What is you area’s score and % of surveys?
What reasons do patients give?
What actions are being taken?
Are you displaying the results?
Also ask 9 or 10 other questions about experience
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Question 4 : Are they responsive?
•
•
•
•
Reporting Adverse Incidents
Nutrition and hydration
Intentional rounding
Productive ward
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Reporting adverse incidents
Management
• Attend to injured person
Further information via the intranet:
• Inform appropriate people
•
Adverse Incident Reporting
• Make the environment safe
•
Risk Management
• Remove (but retain) faulty medical
device or equipment from service
•
Health and Safety
•
Key contact numbers:
•
Corporate risk and assurance team
• Apologise
• Document incident
• Report Adverse Incident onto Datix
If Serious Incident or RIDDOR, call the
Risk or Health and safety team
Ext 2166 - 4966, 4054 – 4050
•
Health and safety team
Ext 3309 – 4043
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Reporting adverse incidents
Datix – adverse incident monitoring system
Datix can be accessed via SGH intranet under Applications; Non Clinical Applications
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Effective Hydration
• A red lid on the water jugs and a red tumbler
signal to staff that these particular patients
need help with drinks and fluids
• Nutrition boards will need to identify which
patients require jugs with red lids/red tumblers
– magnets will be available soon.
• All patients or fluid charts require close
monitoring and documentation of fluid intake
and output, use red tumblers/jugs with red lids
• Always check they may be restricted on fluids.
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Intentional Rounding (comfort or hourly rounding)
• A simple check - is everything ok?
• Many staff do already but not always - patients say they often don’t see
staff
• Regularly checking on patients comfort needs
• Reduces harms (falls, pressure ulcers) complaints, and use of call bells
• Patients reassured as know they will see us regularly
• Ensure a patients know who is caring for them
• Sometimes hourly but should be frequent
• Pain, drink, comfort, help with toilet, have their call bell?
• Being present in bay doesn’t mean you are available to all patients
• Gives patients “permission” to ask us things as often think we are too
busy
• Should be documented but kept simple
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Productive ward
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•
•
•
•
•
•
•
•
•
This national initiative aims to help frontline staff release more of their time to care for patients
directly
Each area undertakes a baseline assessment of how they are doing. It helps to identify how much
time is spent on direct patient care as well as identifying the non value adding activities and areas
of waste
Staff are taught the LEAN service improvement methodology of Sort, Set, Shine, Standardize and
Sustain
Teams identify their key performance indicators for their area and devise an action plan for
improvement
The aim is for the ward to become well organised – this will include organising store rooms so that
you are able to find what you are looking for within 5 seconds of going in there, identifying space
for equipment (all reduces the time wasted looking for nursing equipment)
A ward vision is created which provides clarity on what staff should be delivering and what patients
can expect
Direct care time audits are undertaken to identify the percentage of time staff are spending on
direct care with their patient group,. The audit identifies areas of waste and areas for improvement
There are a variety of guided modules, set over 16 weeks, for wards to follow in order to improve
the area of waste identified
Just completing a ten minute module contributes to your professional development
The Productive Ward is currently under review and will be relaunched in 2014
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Question 5 : Are they well led?
Supporting staff
Temporary Staffing
MAST
Staff Appraisals
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Supporting Staff
Staff are our greatest asset. It is important that they have access to a
good induction, feel well supported and can access appropriate
training and professional development opportunities.
• All new staff must attend corporate induction where they receive information
about the organisation and the support they can expect as employees
• Induction at local level must include information on supervision that is available
during the course of their employment and how supervision works
• Our appraisal system provides a forum where employees can discuss their role
and their performance with their manager and identify any concerns they have.
• Every employee has the right to an annual appraisal
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Supporting staff
• The appraisal allows the manager and employee to identify any personal and
professional development needs to help them improve their job performance
• We run sessions for staff on being appraised so they can understand how best to
benefit from their appraisal
• We aim to have an environment that is free from harassment. Staff are encouraged to
report any incidents of harassment and bullying to their manager
• We offer additional support through a helpline staffed by our staff counsellors.
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Supporting staff
• We encourage all staff to be open about any mistakes that may be made, and we
welcome open communication about concerns at work (we have regular staff
safety forums)
• If an employee is worried about a risk or wrongdoing at work, whether it is to do
with the safety of a patient, financial misconduct, poor practice or criminal
behaviour, they are encouraged if possible to talk or write to your line manager or
lead clinician
• If they feel unable to do this, our Raising Concerns at Work (Whistleblowing) Policy
sets out how to contact a non-executive director or external sources of support
such as Public Concern at Work.
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Temporary Staffing
Bank Registrants
•All bank registrants have met the same rigorous pre-employment
checks that the Trust’s substantive staff have.
•At the point of readiness to work shifts, each new bank registrant
attends the Corporate induction to learn about the organisation and
the support available.
•On placement to a new area a local induction process is carried out
to familiarise the bank registrant of layout and necessary
information relevant to the ward/dept.
•Regular feedback about agency workers is requested and all
concerns are dealt with by the Staff Bank and the relevant agency
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Mandatory and Statutory Training (MAST)
Key knowledge and skills for all
• All staff must complete MAST training to ensure they have the relevant level of
knowledge for their specific job role. MAST training requirements are determined as
part of the Trust’s Training Needs Analysis.
• Compliance rates for these mandatory topics form part of Trust inspections by the
Care Quality Commission, NHS Litigation Authority and the Trust Board.
• The training provision and frequency for these core subject areas are led by subject
matter experts and are relevant for all staff groups. The majority of these are completed
via eLearning.
• eMAST is found at http://learn.stgeorges.nhs.uk and individual staff log in to access
their specific list of MAST subjects to complete.
• All new starters will attend Trust Induction on their first day of employment and will
receive their eMAST user account details in order to commence their MAST training
requirements. This is followed by a local induction to identify any additional training
needs.
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Mandatory and Statutory Training (MAST)
Your responsibility
•
The Trust target for compliance in these core topics is 95% Information
Governance, Infection Control, Safeguarding Adults, Safeguarding Children,
Equality, Diversity & Human Rights, Health & Safety, Fire Safety, Resus, Moving &
Handling, Conflict Resolution
•
Managers can check their own compliance and that of their team by reviewing the
reports on WIRED (the Trust’s compliance reporting tool) which is found under
non-clinical applications.
•
MAST compliance is supported by the staff appraisal process and is the
individual responsibility for all staff.
•
Compliance is measured through assessments of knowledge in each subject area
using multiple choice questions which are supported by an eLearning package for
those who do not achieve the 80% required pass mark on their first attempt.
•
Further support and advice is provided on the Education & Development MAST
webpage and the team are available on ext 4028
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STAFF APPRAISALS
Everyone’s responsibility and opportunity
• There is a joint responsibility between individual staff and managers to organise an
annual formal appraisal and regular performance reviews throughout the year.
• An appraisal is an opportunity:
• For an open two-way discussion between an individual and their line manager, to
review the individual’s performance during the previous 12 months
• To discuss learning, support and development needs and embed Trust values
• To establish agreed objectives for the forthcoming period in line with Trust strategy
• On completion of an appraisal, manager’s must ensure they email their staff member’s
name, department and appraisal date to [email protected] in order to
maintain up to date staff records
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STAFF APPRAISALS
The reasons for an appraisal and further information and advice
•
Appraisals are essential for the effective management and evaluation of staff providing a
formal, recorded, regular review of an individual's performance. Appraisals help develop
individuals, improve organisational performance, and feed into business planning.
•
Goal-setting helps management monitor standards, agree expectations and objectives, and
delegate responsibilities and tasks. Staff appraisals also establish individual training needs
and enable organisational training needs to be analysed and planned for the future.
•
Previous staff surveys have reported the majority of staff are successfully undertaking annual
appraisals
•
The Appraisal Policy and paperwork can be found on the Trust intranet under staff related
procedural documents
•
For those new to appraising staff, training dates are found on the Education & Development
webpage
•
If you would like further information please contact the Education & Development Appraisal
team on ext 0837.