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Corporate Trust InductionA warm welcome to all new staff at South Tees Hospitals NHS Foundation Trust

A message from the Chief Executive

Welcome to the South Tees Hospitals NHS Foundation Trust. I hope you are settling in to your new job and are getting to know your team and the trust.

It is very important to me that you feel welcome and valued. Whether you are working directly with patients or not, you are all helping the trust to provide safe, high quality patient care, and that is the vital part of all our work.

You will find out more about the trust during this induction day. This is an important part of your getting to know the trust, but it is equally important for us to get to know you and share our values with you.

It is also important to me that you have the opportunity to develop your career at South Tees and that you want to stay with us. There are many services in place to help you do this from in-house training to making use of the workplace nursery.

At the end of your induction you may still have questions or comments you would like to make. If this is the case then please feel free to email me at [email protected] and I will reply to you within four working days.

Thank you for choosing to work with us at South Tees.

Professor Tricia HartChief Executive

SOUTH TEES HOSPITALS NHS FOUNDATION TRUST – CORPORATE INDUCTION HANDBOOK

Revised March 2014 Page 1 of 62

CORPORATE TRUST INDUCTION

AIMS & INTENTIONS FOR THE DAY • To formally welcome new staff to the Trust and provide an opportunity to meet new starters • To describe how we operate as a Trust, our core values and our priorities.

• To provide an opportunity to learn about the range of services & benefits for our staff

• To provide statutory and mandatory training for new staff joining our Trust to ensure that they

are informed of important processes, policies and procedures in accordance with our legal and statutory policies

LEARNING OUTCOMES: –

By the end of the event staff will have:

• A comprehensive induction programme including a welcome from the Chief Executive and input from Trust representatives • An opportunity to ask questions & clarify

• An awareness of a range of Trust policies and procedures to apply within the work area

• An opportunity to meet other new starters to the Trust

• The opportunity to browse a range of information ‘stands’ during the lunch break

• Certificate of attendance issued at end of day

• Corporate Trust Induction handbook to accompany the day is available on both the internet and intranet



CORE VALUES We want to succeed in delivering the best possible care to the patients we serve

To achieve this our principles and values are:- We put the needs of patients at the centre of everything we do We do this through:-

Treating patients with honesty, openness and respect

Developing good partnership working with patients and carers

Protecting each patient’s right to courtesy and dignity, as well as their spiritual and cultural needs

Avoiding pain and suffering Having no unwanted waiting or delays

Ensuring no waste We continuously seek to improve the service we deliver to patients

Through:-

Practicing efficient and effective team working by committing to achieving common goals

Working in partnership across health and social care to provide a seamless service

Providing a safe and clean environment that promotes patients’ comfort and well being

Measuring what we do against agreed standards and outcomes

Using evidence, best practice and feedback

Encouraging an environment of mutual challenge

Recognising and celebrating excellence in service delivery

Staff will support, respect and value each other

Through:-

Effective Communication and understanding

Involving staff in planning and decision making that effects them and the services that they provide

Supporting staff to reach their full potential

Leadership at every level reinforcing the values through appropriate behaviours

Having fair and consistent employment practice

Recognising achievement at all levels in the organisation. Tricia Hart Chief Executive

core values/8 November 2006



CONTENTS OF CORPORATE TRUST INDUCTION HANDBOOK

Description Page

1 Index 3 2 Human Resources Directorate Information 4

3 Emergency Preparedness 8 4 Patient Safety & Risk Management Department 11

5 Health and Safety 14 6 Patient Relations Department 17

7 Fire Safety Awareness 20

8 Payroll information (inc SMART parking information) 24 9 NHS Pension Scheme 32

10 Infection Prevention and Control and Healthcare Associated Infections 36 11 Local Counter Fraud Service 39

12 Information Governance 44 13 Safeguarding Children 48

14 Safeguarding Adults 50 15 Mental capacity 51

16 Occupational Health 52 17 Ministry of Defence Hospital Unit (MDHU) 55

18 Staff Side Unions Information 56 19 Spiritual Care and Chaplaincy 57

20 Library 58 21 Resuscitation Department information 59

22 Useful Telephone Numbers 61 23 Identification badge application form 62

24 Notes page 63

Here is the link to the opening page on the South Tees Hospitals NHS Foundation Trust intranet site: http://stas16/intranet/ All policies can be found under ‘Trust Policies’ on the intranet site: http://stas16/intranet/policies/ Here is the hyperlink to the Induction Policy: http://stas16/intranet/wp-content/uploads/2013/12/Induction-Policy-P40.doc Local Induction Please note that all staff should receive a local induction within their respective department. Further information is contained within the Induction Policy.

A local induction checklist MUST be completed and forwarded to the relevant department as outlined in the policy.

http://stas16/intranet/

http://stas16/intranet/policies/

http://stas16/intranet/wp-content/uploads/2013/12/Induction-Policy-P40.doc

http://stas16/intranet/wp-content/uploads/2013/12/Induction-Policy-P40.doc



THE HUMAN RESOURCES DIRECTORATE

Human Resources is one of the Trust’s Corporate Directorate’s providing support services across all Divisions and Directorates in the Trust – for the benefit of staff and in turn our patients. Our goal is to support and advise managers and staff by working in partnership to achieve best practice in people management and policy development and implementation. The Directorate has 112 staff and consists of the following departments:-

Learning & Development – provide reports to managers in relation to staffs’ mandatory

training status; facilitate a variety of mandatory training events to enable staff to be compliant. Co-ordinate delivery of personal development training. Provide reports to managers regarding appraisal uptake; support managers & staff to participate in appraisal process using KSF outlines by providing advice, training and information.

Medical Staffing - assist managers to recruit consultants and compliance with European

working time directive (EWTD)

Nursery - Supports organisations staff in returning to work, commencing employment at the hospital with quality childcare provision. The nursery is open 52 weeks of the year from 6.45am – 6pm excluding weekends and bank holidays. Childcare voucher scheme - The nursery promotes Fideliti (www.fideliti.co.uk) childcare

vouchers, which provide a saving for staff whilst paying for childcare.

Carer Support – Information on Carer support is available in the Flexible Working policy

and Special leave policy. Further information and advice can be sought via Line Manager or Human resources.

Occupational Health Service – health assessments, sick absence management, back

care support, immunisation, physiotherapy etc.

Recruitment HR operations - assist managers to recruit staff through the recruitment

process

Staff Benefits - provide a range of staff benefits information and services.

To access the Staff benefits directory handbook www.nhshandbook.co.uk Click on ‘NHS Staff Login’ along the top bar (blue) Select the Trust and add the following login. ‘nhs659t’

Vocational Training - Vocational Training (VT) provides a demand led learning service to

meet the strategic aims of the organisation and to support the continued professional development requirements of staff. VT has actively sort to diversify and broaden its learning provision to meet the continually changing needs of the workforce and their access to vocational forms of learning and has established an excellent reputation for the delivery of high quality training programmes; in 2012 the department was Graded as a 2 (Good) following Ofsted Inspection.

The Team provide impartial information, advice and guidance (IAG) to enhance the continued professional development and career advancement of staff and can support managers with the development of new qualifications. VT can help source and coordinate funding to support training delivery where necessary and can act as a referral service,

http://www.fideliti.co.uk/

http://www.nhshandbook.co.uk/



directing you onto appropriate partner organisations, if they cannot meet your training requirements.

Further details on the range of qualifications available can be found on the Trust’s intranet site. Alternatively, for further information or a confidential discussion, please contact the VT department on 01642 854744 at JCUH or email: [email protected]

Workforce Planning & Information - support managers and the organisation with staff

data / info.

Important policies to mention

The Human Resources Directorate develops Trust policies in partnership with staff, managers, staff side and the Trust Board providing guidelines to support and protect staff and the organisation. Please make yourself familiar with the range of policies which can be viewed on the staff intranet by clicking the following link: Link to policies Equality & Diversity

The Trust is committed to equality of opportunity for all patients and employees and is committed to employment practices, policies and procedures which ensure that no patient, employee, or potential employee, receives less favourable treatment on the grounds of race, colour, nationality, ethnic origin, gender, sexual orientation, marital status, age, disability, religion, belief, gender reassignment, employment status or trade union membership. To ensure employees are supported in achievement of this commitment there are number of policies in place within the Trust. The policies include; Equality in Employment, Dignity at Work and The Code of Conduct. In addition there is a mandatory requirement for all employees to complete the Dignity at Work / Harassment and Bullying e-learning package once every 5 years. The e-learning package is currently being updated to include Equality & Diversity training (January 2013).

The Trust recognises the diversity of people and will promote an environment, which respects those differences. You have the right to be treated equally and fairly in all aspects of your employment. You also have a responsibility to adhere to those principles in relation to others. A key part of the Equality Act 2010 for public organisations is the Public Sector Equality Duty. There are two parts of the duty which public organisations have a legal responsibility to do: a) Publish information to demonstrate compliance at least annually starting from 31 January 2012. The information must include information relating to persons who share a relevant protected characteristic who are -

i) its’ employees; ii) other persons affected by its policies and practices

b) Prepare and publish equality objectives at least every four years starting from 6 April 2012. To aid the Trust in the in the identification of key objectives, we used a tool developed by the Department of Health called the Equality Delivery System (EDS). At the heart of the EDS is a set of 18 outcomes grouped into four goals. These outcomes focus on the issues of most concern to patients, carers, communities, NHS staff and Boards. The outcomes focus on getting it right for people, be they patients, other members of the public and staff. It is against these 18 outcomes that performance is analysed, graded and action determined.

mailto:[email protected]

http://stas16/intranet/policies/policies/human-resources/



The four EDS goals are:

1. Better health outcomes for all

2. Improved patient access and experience 3. Empowered, engaged and included staff

4. Inclusive leadership at all levels

The Trust’s Board of Directors received a presentation on the grading assessment undertaken within the Trust along with 5 recommended objectives for the forthcoming four years which were agreed and ratified in March 2012. A summary of the objectives are outlines below: Objective 1 - Improve the information available for patients on all protected characteristics. Objective 2 - Increase the Trust’s engagement with patients and the public from all protected characteristics. Objective 3 - Improve the experience of older people using our services. Objective 4 - Make Equality & Diversity training mandatory for all staff. Objective 5 - Reduced the incidents of discrimination, bullying and harassment of all staff, and significantly reduced the incidence for staff with a disability, as reported in the NHS staff survey.

An Equality Impact Assessment (EqIA) is a tool for examining the main functions and policies of an organisation to see whether they have the potential to affect people differently, particularly the protected characteristics as outlined in the Equality Act. The purpose of an EqIA is to identify and address existing or potential inequalities, resulting from policy and practice development or revision of a policy. On completion of a policy, business case or service development plan the authors should complete an EqIA. By the completion of an EqIA it is assisting the Trust in meeting its legal responsibilities with regards to the Equality Act. SUMMARY OF KEY BENEFITS AND SUPPORT SERVICES AVAILABLE FROM YOUR HUMAN RESOURCES DRIRECTORATE:

An annual programme of learning & development events – mandatory, staff development, access to accredited and external learning opportunities / conferences

Access to e-learning / computer based learning opportunities providing alternative and blended learning solutions for all staff

High quality, information & advice and guidance for managers and staff

Dedicated Learning & Development Team supporting staff and managers to maintain and develop skills and knowledge for their role, the developing service and their future career – work in partnership with Trust Training Links in Divisions and Directorates.

Matrix Accreditation; a National Quality Mark for IAG

Access to funded training opportunities and nationally recognised qualifications which can enhance career and earning potential.

Specialist onsite tutor providing 1-1 support in Maths and English.



Accredited Training Centre with City & Guilds and OCR Awarding Bodies.

Individualised training, adapted to enable staff to develop the necessary skills to meet the requirements of their job descriptions and KSF outlines.

Opportunities to progress along the NHS skills escalator.

Work Placement Co-ordinator - provides support and advice on how to access and coordinate work experience placement opportunities across the Trust

Staff Benefits Scheme providing staff with a range of benefits and local services e.g. Home computing initiative, NHS family lease car scheme, staff lottery, Christmas savings club and others.

Access to an excellent Day Nursery at The James Cook University Hospital for children aged 6 weeks to 5 years.

Access to high quality, consistent advice and training on preparing or conducting a staff development review (SDR) and support / information on the Knowledge & Skills Framework and KSF outlines.

Excellent occupational health team – back care support, immunisation, health promotion events, health assessments, and staff counselling.

Information on job opportunities in the trust - Job opportunities

USEFUL CONTACTS IN THE HUMAN RESOURCES DIRECTORATE:

Service Contact Base of service Provision

HR general enquiries HR Secretarial team JCUH Ext 54803 or 54811, Friarage 62006

Langbaurgh House 01287 204295

Internal / external Training Enquiries

Learning & Development Team

Or your Training Link within your division or

directorate

JCUH Ext 52823 or Ext 54710 Email: [email protected]

Langbaurgh House 01287 204295

Contact details for training links available from your line manager, through local induction or Divisional Training links

Advice & Guidance on Staff development

Learning & Development JCUH Ext 55610 or 01642 835610 or Ext 52823

Knowledge & Skills Framework / Staff Development & Review

Zoey Francis Personal Development

Co-ordinator (Monday – Wednesday)

JCUH Ext 53775

Nursery Provision Michelle Tullius, Dilys Atkinson

or Clare McAllen

JCUH Ext 52810 or External 01642 282810

Childcare voucher scheme Fideliti 0800 288 8727

Recruitment Team General Enquiries JCUH 54610 or Friarage 63071

Staff Benefits Scheme JCUH 54610

Vocational Training Team Claudia Godfrey JCUH 54744 Email: [email protected]

Work Placement Coordinator Gerard Finn JCUH 52490

Workforce Information Manager Teresa Wilson JCUH 52881 Occupational Health enquiries General enquiries JCUH 53204 or Friarage 62032

Finally, we hope you enjoy your career in South Tees Hospitals NHS Foundation Trust. If we can be of any further help

please contact us at any time.

http://www.jobs.nhs.uk/cgi-bin/advancedsearch.cgi?refine=Y


http://stas16/intranet/services-a-z/learning-and-development/training-links/




EMERGENCY PREPAREDNESS Introduction

As a trust we are used to dealing with emergencies every day. However there may be occasions when we face an emergency that is outside our day-to day capabilities. There may also be situations in which our ability to provide our core services is seriously compromised, resulting in a significant disruption of services. These are known as major incidents or emergencies and require special response arrangements to deal with consequences. Emergency Preparedness, Resilience and Response (EPRR) is defined by a series of statutory responsibilities under the Civil Contingencies Act 2004. This requires NHS-funded organisations to maintain a robust capability to plan for, and respond to, incidents or emergencies that could impact on health or services to patients.

(EPRR guidance 2013) Risk Assessment

Risk assessment is the basis for emergency planning and ensures that as a trust we have plans that are relevant to the risks present and proportionate to the severity and the likelihood of occurrence. Each locality has a Community Risk Register which describes the particular hazards in the area. The main risks for the areas served by the trust in Cleveland and North Yorkshire are:

Transport accidents (rail, road, sea and air) Accidental or deliberate release of chemical, biological, radiological or nuclear materials Outbreak of pandemic human disease Adverse weather

Major Incident Plan

The Major Incident Plan describes how the trust will provide comprehensive hospital support to a major incident. The plan is generic because no single plan will fit each and every type of emergency. It has been designed to provide a flexible framework to enable the trust to respond to a wide range of emergencies and incidents, with the ability to expand available resources to meet any foreseeable increase in scale or duration of an emergency. The plan also includes specific plans which relate to particular kinds of emergencies. These give a more detailed set of arrangements which go beyond the generic arrangements, e.g. plans for chemical, biological or radiological incidents. In the event of a major incident being called, there is a requirement for the rapid and efficient mobilisation of key staff, with the objective of preparing the trust very quickly to the level required to receive a large number of casualties. This is achieved by a telephone call out cascade system. Key personnel are contacted by Switchboard staff and are responsible for initiating departmental plans. The trust’s response is managed and co-ordinated by the Hospital Co-ordinating Team (HCT) who will be based at The James Cook University Hospital. This includes incidents involving FriarageHospital. The HCT have executive control of all the trust’s resources to meet the needs of the incident and maintain the essential functions of the organisation.



The plan includes action cards. These provide an easy guide to an individual’s role, responsibilities and actions during a major incident. Staff should act in accordance with their Action Cards in line with their on duty / off duty status at the time. Pandemic Influenza Plan

A pandemic occurs when a new influenza virus, which people have no immunity to, emerges and starts spreading as easily as normal influenza. One of the main emergency planning challenges is being unable to predict the timing and exact severity of a pandemic. Although there was the swine flu pandemic in 2009, the Government has assessed that one of the highest current risks to the UK is still the possible emergence of a human pandemic disease. It is therefore essential to pre-plan how resources can be maximised and how services will be maintained for both influenza and non-influenza patients. The Pandemic Influenza Operational Response Plan forms part of the trust’s overall response to emergencies and shares many of the processes and procedures which would be invoked during a major incident. It is based on an ‘escalation model’ which means that different actions will be carried out in response to trigger points as the pandemic progresses. It also addresses the particular challenges of dealing with the longer term impact of an influenza pandemic outbreak to ensure patient services are delivered, as far as reasonably practicable, during a period of unprecedented demand for services and staff absence. Business Continuity Planning

This trust delivers a wide range of services to its local communities. Failure to deliver these services could have a detrimental impact on the health of the public and the viability of our business. Business continuity management is concerned with managing risk to ensure that, at all times, the organisation can continue operating to, at least, a pre-determined minimum level, in the event of a major disruption. These risks can be from the external environment, e.g. flooding, power failure, severe weather, or from within the organisation, e.g. system failures, loss of key staff. In line with the requirements of the Civil Contingencies Act 2004, the trust has undertaken a programme of work on business continuity to ensure that it can continue to provide services during a major incident, as far as is reasonably practicable, and to recover from the additional pressure that the incident would place on the organisation. This work is ongoing and includes both internal arrangements and also the arrangements with various external PFI partners, contractors and service providers. A major incident or emergency which demands a sufficiently large scale response from the trust may become a business continuity problem if the response required is at the limits of the trust capacity and begins to divert resources away from other important functions. An influenza pandemic would be the most extreme example of this, because demands for health services could reach a very high peak when many of our staff would be unable to work. Multi-agency working

Emergency planning in Cleveland and North Yorkshire is based on well established multi-agency partnerships. The trust is fully engaged in these partnerships and is represented and involved at appropriate levels in the various local and regional emergency planning arrangements and in the supporting work streams.



Training and Exercising

Training should underpin planning to ensure that staff are equipped with relevant knowledge and skills and have the confidence to deal with emergency situations. Exercising is the most effective way to test and validate the effectiveness of emergency plans. The trust undertakes its own exercises and participates in exercises run by partner organisations and also those on a larger scale run either regionally or nationally. Summary

Major incidents or emergencies are unpredictable and can occur at any time day or night. It is essential that we are prepared and able to respond at short notice to a range of emergencies. Every member of staff plays a vital role in ensuring a professional response. As such, it is important that you are familiar with how the trust will operate during such an event, what role you may play and what other organisations we will be working with. The Major Incident Plan is available on the trust intranet. Please read it, discuss it and practice it within your departments, wards and clinical areas to help you prepare to meet the challenge. Contact Details

If you have any questions or require further details, please contact: Donna Jermyn, Emergency Planning Manager Ext 55960 Liz Harvey, Assistant Emergency Preparedness Officer Ext 53576

Updated November 2013



PATIENT SAFETY AND RISK MANAGEMENT DEPARTMENT

Directorate of Healthcare Governance: Our aim is ‘Actively Reducing Risk’, by

Improving quality of patient care. Improving safety for patients, staff and visitors.

Patient Safety and Risk Department’s Role

To ensure there is an integrated approach to Patient Safety and Risk Management by adopting the ethos of the National Patient Safety Agency (NPSA) ‘Seven Steps to Patient Safety’

To provide advice, assistance & support on Patient Safety and Risk Management issues. Why Should We Report & Learn?

In a service as large as the NHS things sometimes go wrong. When they do, the response should not be one of blame and retribution but of learning. The emphasis is on reducing risk to patients, staff and others and responding appropriately when incidents do occur. This is a fundamental pledge made by the Government. As a result, the National Patient Safety Agency (NPSA) was

formed with a remit of reviewing all patient related incidents in order to learn lessons, and share knowledge. Being Open with patients - National Reporting & Learning System (NRLS) Recommendations - The NRLS recommends that Healthcare Organisations, acknowledge,

apologise and explain what happened to patient’s, their families and carers when a patient is harmed or has died as a result of a patient safety incident as soon as practicable. It is also essential to engage in proactive risk management activities such as risk assessment,

actively listening to patients’ complaints and comments. These enable the early identification of many things that could go wrong so that we can implement appropriate tools, actions, plans and control measures to minimise the likelihood or the consequence of an incident.

Driving Forces

Standards for Better Health

April 2009 – New Care Quality Commission

National Patient Safety Agency (NPSA)

Medical and Healthcare Products Regulatory Agency (MHRA)

Health & Safety Legislation

NHS Litigation Authority Risk Management Standards

Trust commitment through the Risk Management Strategy National Safety First Campaign

Safer Care North East

Being Open – NPSA 2005, revised 2009. Price of Failure The cost of an incident occurring should not only be seen in terms of monetary value, the human cost of anguish to not only the patient but to those individuals involved must also be considered. Various aspects are:

Individual & Family

Staff

Financial, including, fines, compensation, insurance premiums Reputation of the organisation



All of the above may lead to a loss of public confidence not only in the healthcare professional but, if not appropriately addressed, in the NHS as a whole. Therefore this Trust has adopted an open and fair culture in which incidents and near misses must be reported. Where a detailed investigation is required it will be conducted in an open and supportive way. This will focus on systems, processes and contributory factors rather than individuals. Of course if the investigation uncovers unprofessional conduct, this may be subject to normal disciplinary procedures. Organisational Culture

Open

Honest

Risk Management processes

Quality of Care

Encourage reporting Policies can be found on the Intranet. Take Home Messages

Report all incidents and near misses

Some incidents have to be reported externally to NPSA, HSE, MHRA, etc. Review incident, complaint & claims data in order to learn from these

In doubt, contact us

Be actively involved with the risk management process.

We need you to support a Root Cause Analysis Investigation Patient Safety and Risk Department: Ext: 54699

There is always some one from patient safety on call for advice, assistance or support out of hours, weekends and bank holidays and they can be contacted through switchboard.

TRAINING

Datix Web Based Incident Reporting System Training

Training on how to report an incident form electronically should be given to all staff as part of

a local induction to their own ward or department. Each division has a DATIX link – usually within the Governance team who would be able to recommend DATIX support within a specific area.

Staff responsible for investigating and coding incidents should receive dedicated training within their division. However, if this is not available the DATIX manager should be contacted to suggest a link person who could offer training.

Staff who are required to finally approve (sign off) incidents – for example clinical matrons, directorate managers, directors or governance leads should contact the DATIX manager to arrange for a specific session if necessary.

Please contact ext 52528



Risk Assessment and Root Cause Analysis Training 1. Risk Assessment Training (Full day)

The staff who should attend this training session are those who will have responsibility for ensuring that Risk Assessments are carried out in their wards or departments i.e. managers, ward sisters, staff nurses and allied health professionals. It covers clinical, health and safety, fire and information governance risk assessments.

2. Root Cause Analysis (RCA) Training

The staff who should attend this training are those likely to lead or be requested to assist investigate serious untoward incidents. This will include ward & department managers, senior members of the multi-disciplinary team, clinicians, clinical matrons and governance leads. Access to RCA E-Learning training is via the Trust Intranet site or via the following link - http://www.nrls.npsa.nhs.uk/resources/?entryid45=59901 Presented sessions are provided by the Strategic Health Authority (SHA) on an ad hoc basis. Support for staff undertaking RCA investigations is provided by the Patient Safety Manager. 3. Specific Health & Safety Risk Assessor Training (1 Full Day)

Control of Substances Hazardous to Health Manual Handling (Patient & Object handling)

Display Screen Equipment (DSE)

These sessions are intended for ward & department managers (or their nominated deputies) who will be responsible for carrying out these specific Risk Assessments. If in doubt whether attendance for any of these courses is required, please seek advice from Health and Safety on Ext 54699

4. Medical Equipment Training

There is an ongoing programme of competency based training for Infusion Devices for nominated Key Assessors for most infusion devices in use. Other medical equipment training is provided on an ad-hoc basis coordinated either via the Medical Devices Manager or the Divisional Practice development link. There is a Medical Devices training Policy – G78 which contains a Medical Devices Training Pack as an appendix. Dates for training can be found on the healthcare governance intranet site. Contact Details Ruth Holt Director of Nursing and Quality Assurance Ext: 54669 Patient Safety Manager Ext: 54669 Chris Spence Local Security Management Specialist/Health & Safety Lead Ext: 54669 Lee Dodds, Stephen Bell & Michelle Collins

Health and Safety Advisors Ext: 52004, 53526 & 54632 Lee Dodds Medical Devices Manager Ext: 54471 Out of hours please contact Risk on call via switchboard

http://www.nrls.npsa.nhs.uk/resources/?entryid45=59901



HEALTH & SAFETY AIMS AND OBJECTIVES

Provide an overview, with Trust examples of: What Health and Safety is Why it is important Individual responsibilities Where to find more information

Introduce the Health & Safety Department

The Health and safety department consists of a Local Security Management Specialist / Health and Safety Lead and Three Health & Safety advisors. Their role is to advise all levels of the organisation on effective Health and Safety Management and to facilitate the process. They can be contacted directly on 54699. The importance of health and safety

The Trusts Patient Safety and Risk Management Strategy 2008 - 2011 sets out the Trusts commitment to Health and Safety in its Aims & Objectives. The Trust encourages a pro-active approach to health & safety and encourages consultation and communication on safety matters with all staff.

The Health and Safety Executive (HSE) are the enforcement body for health and safety and they have publicised their commitment to continuing improvement of Health and Safety within the healthcare sector. Ineffective management of health and safety can cause pain, suffering and even death to Individuals. This can also effect an organisation with increased pressure on staff, low morale and poor public perception being some examples. Ensuring the health and safety of staff, patients, visitors and others is a legal requirement. Breaches of health & safety law can result in criminal prosecutions and associated punishments such as fines and imprisonment. Individuals can also instigate civil proceedings with compensation being awarded for pain and suffering experienced. This in turn leads to increased insurance premiums. Responsibilities

Health and safety is everyone’s responsibility and the Health and Safety at Work Act 1974 gives specific details of what these are. Employers must ensure the health, safety and welfare of their employees at work but this duty is extended to others who may be affected by their work activities e.g. patients, visitors, contractors. Employees are also given specific duties. Employees must:

Take reasonable care of themselves and others Co-operate with their employers on matters of Health & Safety Not misuse or interfere with anything provided for Health & Safety



Tools

It is impossible to provide employees with everything they need to know in one short lecture and therefore there are a number of tools, which have been developed to help them fulfil their responsibilities.

All new employees must receive a local induction into their work area. This is vital so that they are aware of facilities, procedures and emergency plans in place.

Trust policies including the Health and Safety Policy are available via the Trust Intranet. In addition, the Health and Safety department have their own intranet web site that details all recently issued safety alerts and all copies of risk assessment forms for clinical and non clinical activities.

Other information sources are also available such as signs & notices, risk assessments & safe systems of work, protocols and manufacturers’ guidance.

Risk Assessments

A risk assessment is a systematic 5 steps and documented approach to identifying and evaluating what may cause harm to persons within the workplace, so that effective decisions can be made as to whether enough precautions have been taken or whether more should be done. The five steps are:- 1 Identify the hazards 2 Decide who might be harmed and how (what can go wrong? who is exposed to the

hazard?) 3 Evaluate the risks (how bad? How often?) and decide on the precautions (is there a need

for further action?) 4 Record your findings, proposed action and identify who will lead on what action. Record

the date of implementation 5 Review your assessment and update if necessary Risk assessments should be carried out by competent persons within each work area and communicated to anyone who may be affected. As previously mentioned training in risk assessment is accessible via the health & safety department.

Proactive & Reactive Monitoring

The Trust uses the Datix Incident reporting system for recording incidents including those where no actual damage or harm occurred, these are called near misses. Near miss reporting enables the organisation to proactively monitor and manage emerging risks before actual incidents occur.

Statistically, near miss reporting materialises in :- 600 “near miss” reports Of which 30 result in property damage; Of which 10 result in minor injuries; Of which 1 results in serious or disabling injury. Therefore, the importance of near miss reporting is paramount.

Trusts that report incidents regularly suggest a stronger organisational culture of safety. They take all incidents seriously and link reporting with learning. Statistics from DATIX and the incidents reported are used to produce governance reports and performance review reports in order that action plans can be developed to prevent reoccurrence of incidents.



Serious incidents must be reported immediately by telephone. This ensures that an investigation can be immediately instigated and any action plans necessary can be formulated and implemented to ensure future similar incidents are not repeated. It also ensures that we comply with the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR).

Reporting of Diseases and Dangerous Occurrences Regulations (RIDDOR)

Accidents at Work, which result in: • DEATH • MAJOR INJURIES (e.g. FRACTURE, DISLOCATION, AMPUTATION) • ADMITTANCE TO HOSPITAL > 24HRS stay • ABSENCE FROM WORK OF MORE THAN 3 DAYS • ASSAULTS, which result in one or more of the above • DANGEROUS OCCURENCES • DISEASES Are reportable under RIDDOR and therefore the Health and Safety Department need to be informed so they can submit the appropriate reports to the HSE. Within the Trust, RIDDOR posters offering further guidance are available in each work area. Electronic versions of the poster are available from the Health & Safety department.

Important Contact Numbers

Health and Safety Office (in hours) Ext: 54699

Health and Safety (Out of hours) Advisors on call via switchboard

Security Rapid Response Ext: 2323

Faults/ Repairs to utilities / environment Ext: 53111

Medical Engineering Ext: 54655

Driving on Trust Business

Whether you are driving your own vehicle, a Trust vehicle or leased transport, you have a responsibility. Please read – Trust Policy HS 36 “POLICY AND PROCEDURE FOR THE MANAGEMENT OF DRIVERS INCLUDING SAFETY ASSESSMENT AND TRAINING”, (This policy is on the Trust intranet site) http://stas16/intranet/wp-content/uploads/2013/12/Management-of-Drivers-Inc-Safety-Ass-and-Training-HS36.doc Specific responsibilities are detailed in this policy, including those of the manager and employee.

Defensive driver training seminars are organised twice a year and any employee who drives regularly on Trust business is encouraged to attend. (Complete Appendix D of the Policy and procedure)

If you have any other concerns about driving on Trust business, discuss these with your Manager, or refer to the Policy and procedure for driver management.

http://stas16/intranet/wp-content/uploads/2013/12/Management-of-Drivers-Inc-Safety-Ass-and-Training-HS36.doc

http://stas16/intranet/wp-content/uploads/2013/12/Management-of-Drivers-Inc-Safety-Ass-and-Training-HS36.doc



PATIENT RELATIONS DEPARTMENT

The Patient relations department has a key role in managing, coordinating, analysing, and disseminating learning from patient experience information gathered from across the Trust. Information comes into the department via; direct contact with patients through the PALS and complaints processes and from other patient experience & engagement activity carried out within the clinical divisions such as; surveys, focus groups, interviews etc.

1. Patient Advice and Liaison Service (PALS)

The role of the PALS service is to ensure patients and their relatives have a voice regarding their care and treatment. PALS is in place to listen to what people say, especially when things have gone wrong, and to make sure that the Trust learns from what we hear. When things have gone wrong for someone, whether it is a patient or a carer, PALS is there to offer on the spot advice, and to liaise with the appropriate staff in order to resolve the problem. PALS is an alternative for those who do not wish to raise their concern directly with staff involved in care delivery, and who do not want to make a formal complaint. PALS information about what it learns is used to provide reports regarding trends and analysis to both the Trust Board and to commissioning bodies. 1.1 PALS Process

A PALS enquiry is defined as:

“A PALS enquiry is a concern brought directly to the attention of a member of staff by a patient or other user of the Trust, that is not a formal complaint, but requires action on the part of the Patient Advice and Liaison Service in order to bring about resolution and change.”

Patient Relations Officers follow a process when handling enquiries that is determined by the person making that enquiry. The person making the enquiry may be a patient or relative, and the issues raised may be simple or complex and can range from requests for help in navigating the Trust’s services to serious concerns about standards of care. The enquirer may want to talk to us in confidence, and may not leave a name. We discuss how we might go about solving the problem, who we will talk to, what the likely outcomes are, and the time it will take to achieve them. We treat PALS enquiries in the utmost confidence, and we gain consent, wherever possible, before taking matters forward. The majority of enquiries can be closed within one week. The most valuable part of the PALS process is that we learn from it, and that we feedback to the Trust what our patients and their carers are telling us about their experiences.



1.2 What Staff Can Do To Help Improve The Experience of Patients and Carers with a PALS Enquiry or Complaint:

Any member of staff may be approached by someone with a concern, and they need to be confident about explaining that there are three options for an enquirer to follow:

To talk to a senior member of staff in the ward or department concerned

To talk to a member of the PALS team in confidence If this does not help, or the person definitely wants to make a formal complaint, the

individual should be directed to contact the patient relations department by phone or letter.

NB:

If staff receive a written complaint this needs to be passed to the patients relations department on the day of receipt for processing and to permit acknowledgement within 3 working days.

Positive comments and compliments are just as important, and when comments are made in praise of the Trust we need to hear about these too!

1.3 Tips for dealing with a complainant: Do try to provide a quiet room to discuss their concerns, in order to ensure confidentiality

and privacy. Do consider your own personal safety, and take the appropriate action to ensure you are

not put at risk. Do listen carefully, genuinely take an interest, make the complainant feel you have taken

the matter seriously, make notes, instil confidence that you will take action. o It is important that the complainant feels that their comments have been valued.

Do demonstrate empathy and use phrases such as: “I understand / appreciate.” Do identify the problem and what it is that they want you to do to put it right. Do agree and document the action that you are going to take on their behalf and make sure

that you take it. Do try to achieve a favourable, timely outcome. Do remain impartial:

Don’t be defensive - this may aggravate the individual further and inflame the situation. Don’t condemn staff for their actions, gather the facts. Don’t be afraid to apologise – to say 'sorry' that they have had cause for concern / upset,

etc. You don’t have to agree with them. “I am sorry things haven't turned out the way you expected.”

o An apology isn’t an admission of liability!

Don’t forget to complete an incident report form. Don’t forget to debrief and reflect to avoid negative feelings.

Don’t forget your personal safety:

Zero Tolerance to violence and aggression Security Quick Call: 2323 – all sites.

2. The NHS Complaints Procedure

All staff are responsible and accountable for addressing any verbal concerns and complaints which they receive from the people who use their services in an attempt to bring about a swift and prompt reply and appropriate and effective action. It is essential that issues raised verbally are handled well, and responded to efficiently in order to resolve the concerns in a timely way and to address them satisfactorily. Staff must strive to prevent minor issues becoming formal complaints.



The trust welcomes customer feedback as this enables us to see our services through our users’ eyes. For most people making a complaint is not something done lightly, and we should not be dismissive but grateful for the opportunity to review and make improvements. The trust uses complaints positively to actively reduce risk by improving patient services and safety. Where lessons can be learned from complaint investigations this information must be shared and disseminated promptly and appropriately. The trust’s local targets are to:

Acknowledge receipt of a complaint within 3 working days.

To respond to any complaint within 25 working days, and to conclude a satisfactory Local Resolution.

Those complainants who remain dissatisfied with the trust’s response may request an independent review of their complaint via the parliamentary and health service ombudsman. The trust’s complaints policy is available on the Intranet; Outlook Public Folders; the complaints web page and in Volume 1 General Policy File. Any member of the patient relations team will be happy to provide help or support regarding dealing with complaints whether informal or formal. The patient experience co-ordinator can offer advice or support to staff wishing to collect the views of patients regarding their experience of the service delivered.

CONTACT DETAILS

Linda Oliver Patient Experience Co-ordinator Ext:53832

Barbara Bellamy Patient Relations Secretary Ext:54500

Sarah Smulders Patient Relations Administrator Ext:55019

Sarah-Jane McGreevy Patient Relations Administrator Ext:53840

Complaints email: [email protected] or [email protected]

Margaret Robinson Patient Relations Officer Ext:54807

Emma Dolby Patient Relations Officer Ext:52657

Helen Newman Patient Relations Officer Ext:53627

Mel Rand Patient Relations Officer Ext:55426

PALS email: [email protected] Fax: 01642 282467, Freephone: 0800 0282451

BLEEP Via switchboard







FIRE SAFETY AWARENESS Fire Safety Information

The purpose of this aide-memoir is to provide a quick précis and background of the fire precautionary provisions that are in place in Trust premises and when read in conjunction with the Trust Fire Policy Document HS05 it provides a useful guidance tool on how to minimise the impact of fire and the actions

required should an incident occur. Whilst it is the responsibility of the Trust to ensure that appropriate fire precautionary provisions are

provided and inform/instruct personnel accordingly. It is the duty of every member of staff to acquaint themselves and understand what is required of them to maintain an environment safe from the affects of fire and the action to be taken in the event of a fire emergency, which is detailed on the localised fire

instruction notices that should have been explained to you during your local induction meeting. Fire Prevention

The Trust operates a strict NO SMOKING policy. This ban also applies to the communal areas in the staff residency buildings. For further details see Trust’s No

Smoking Policy Document. For fire to start, three elements are needed: Source of ignition; fuel & oxygen

source (air), recognise this danger and how quickly fire can spread and keep combustible materials (textiles, furnishings, paper, waste etc) away from hot surfaces and other ignition sources, including electrical fittings & avoid clutter.

Turn off where possible electrical equipment when not in use. TV sets in the stand-by mode still pose a risk.

The use of toasters, microwaves and cooking is restricted to designated kitchen facilities. Cooking must never be left unattended and kitchen doors kept closed during the process to prevent cooking fumes permeating beyond the kitchen to

activate smoke detector devices located in other areas, via a wedged open fire door that is a common cause of false alarm occurrences. Unwanted fire signals not only disrupt services and patient care but also divert valuable Fire Service resources

away from actual emergency incidents elsewhere. Wedging a fire door open also contravenes the Fire Regulations.

Maintaining the Means of Escape The purpose of a fire escape route is to ensure that occupants can vacate the

affected area quickly and safely and all exit routes are identified and indicated by appropriate signage.

All escape routes must be kept clear from obstruction at all times and to maintain these safe egress routes associated fire doors must be kept closed, unless the door is held open electronically by an approved device (see info below for further detail).

Designated fire exit doors are normally secured by approved fastenings i.e. panic bolts/pads, thumb turn type devices, however if security control is an issue escape doors will be fitted with electro-magnetic securing devices that release automatically

when a local fire alarm operates to facilitate immediate egress from the affected area. A quick release green button/break glass device will also be fitted in close proximity to these doors.

The purpose of a fire/smoke doors is to prevent fire and smoke spread and to maintain the integrity of the means of escape facilities, therefore fire/smoke doors

must not be held open, other than by electro-magnetic hold open devices which will release the door/s when the fire alarm activates.

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Fire Routine Both the James Cook and Friarage sites are split into a series of fire compartmented

zonal areas that form fire resisting barriers to prevent fire and smoke spread. This arrangement enables the occupants of an affected area to move away from a fire condition and seek temporary refuge in an adjoining zone, a strategy known as

progressive horizontal evacuation. Each zone is provided with automatic fire detection (to provide early warning) that is supplemented by break glass call points linked to the fire alarm network that will provide a continuous alarm in the affected

area and an ‘alert’ signal in all adjoining zones. If you discover or suspect fire has occurred immediately operate the nearest fire alarm break glass call point to alert others. If you are involved in attempting to establish the cause of a fire alarm and

part of your investigation involves entering a room always remember to test the door/handle with the back of your hand, if the door feels warm or you note smoke issuing from around the edges. Do not attempt to enter the room and leave the

door closed. Fire Service responses to fire alarm activations: - To reduce unnecessary attendances by Fires Service

crews to unwanted calls a ‘Call Filtering Process’ is used i.e. Single fire sensor activates system, switchboard delay call to Fire Service for 4 minutes to enable staff/fire team to determine if a response is required (glowing red indicator light will identify activated device).

Switchboard automatically call Fire Service in the following circumstances: - Operation of manual call point or second detector device, 4min time delay is exceeded or at the request of a member of staff.

For further information see details listed on localised fire action instruction notices. The above process does not apply to the Staff Residency Buildings at the James Cook site and residents

therein are asked to adhere to the information listed on the fire instruction notices (Fire Brigade attend on request only)

Members of the Hospital Fire Team respond to all incidents.

Continuous Fire Alarm Patient Treatment Areas

If fire is confirmed the affected zone will be vacated and patients and staff will move away from the area into an adjoining fire zone (a safe refuge). The occupants can

remain here until the incident is dealt with or await further evacuation to another adjoining area, should the need arise. Because of the complexities associated with this arrangement, if you are assigned to one of these areas you must confirm

and acquaint yourself with the local arrangements very quickly.

o The first stage of the evacuation will be to move patients away from immediate danger

o Fire doors throughout the sites have a minimum fire rating of 30 minutes, which ensures that any

outbreak of fire will be contained within the area for a period not less than that specified.

o When leaving an area/compartment ensure all doors are closed to restrict fire spread.

o No one (staff, patients or visitors) should enter a fire zone when the continuous fire alarm signal is

operating, unless they are part of the Fire Team or it is permitted by the Senior Fire Officer.

o Lifts cannot be used in affected fire zonal areas until the fire alarm system has been reset.



Non – Patient Areas

Regardless of the reason for the alarm, occupants of these areas must immediately evacuate the area and

wait at the designated fire assembly point until the all clear is given by the Fire Team Leader. Appointed Fire Warden/s will undertake a quick search of the building/area and pass on the relevant information to the attending Fire Team.

Fire Alarm Intermittent Signal This indicates that the fire alarm has activated in an adjoining area. Ensure all fire doors

are closed. Stay calm and if necessary reassure patients and assess their needs in readiness for possible evacuation.

Fire Fighting

Do not place yourself or others at risk by attempting to tackle the fire unless you have undergone fire fighting training. Leave the area

closing doors and windows behind you.

Fire Discovery If you discover fire always operate the nearest break glass call point, which will ensure an immediate Fire

Service response. Smoke - Is very toxic and therefore it is important to keep your head below the smoke layer.

Gases - Do not attempt to tackle a fire if any of the following are involved

Gas Cylinders Piped Gas Aerosols

Fire Classifications Class A

Fires involving freely burning materials. For example wood, paper, tex tiles etc Appropriate extinguisher medium

Water or Foam Spray Class B

Fires involving liquids or liquefiable solids. For example solvents, lubricants, spirits etc Appropriate extinguisher medium

Foam Spray or Dry Powder (Do not attempt to extinguish running fires) Class C

Fires involving gases Do not attempt to extinguish

Class D Fires involving combustible metals Do not attempt to extinguish

Class E Electrical fires



Appropriate extinguisher medium CO2 (primarily) or Dry Powder (isolate electrical supply if possible)

Class F Fires involving Fats and cooking oils

Appropriate extinguisher medium Foam (Do not attempt to extinguish running fires)

Fire Training

Fire training in hospitals is essential and is a legal requirement. All staff should receive regular training, which will be determined by a local training needs analysis and it is expected that staff involved in direct

patient care will receive instruction more frequently than those who may only be required to evacuate themselves in the event of a fire alarm. All staff should take part in a fire evacuation drill/exercise at least once in every period of 12 months.

It is important to be familiar with the escape routes from your work place and the location of fire alarm call points together with the information detailed on the fire instruction notice (every area should have one),

which will equip you to deal with fire emergencies. Whilst it is unlikely that you will be involved in a major fire, small fires can still be dangerous, so famili arise

yourself with the procedures for dealing with an outbreak and understand your role and responsibilities.

Ensure that you acquaint yourself with the means of escape routes and localised evacuation strategy and remember prevention is better than cure , so play your part in maintaining a safe environment by adhering to the fire safety guidance/instruction documentation.

Contact details Tony Wood Fire Officer Ext: 54914

Revised Trust Fire Officer May 2010



PAYROLL/PENSION MATTERS

The department is open 9.00 a.m. - 5.00 p.m. Monday to Thursday and 9.00am - 4.30pm Friday

Where we are situated: Ripon Ward (next to the Murray Building),

The James Cook University Hospital Fax Number: 854662

Who to contact: Mrs Lynn Biggs, ESR/Payroll Manager, Tel: 282868 ext 52868 Mrs Norma Miles, Pensions Officer. Tel: 850850 ext 53045

Ms Lesley Edwards, Pensions Officer, 850850 ext 53045 When is payday? The last banking day of each month

(This does not include Saturday) By what date do we need to know of any personal/contract changes?

i.e. bank details, new address, promotion, reduction in hours The 6

th day of the month

Timesheets (extra hours/O.T. paid one month in arrears) The 6

th day of the month

Travelling Expenses (Paid one month in arrears) The 10

th day of the month

Tax Office: Tees Valley Operations Office, George Stephenson House, St Marks Court, Thornaby, Stockton on Tees. Tel: 0845 3667865.

Tax reference must be quoted: 406/C7001 Tax is deducted at source from your salary at 20% up to £34,370 per annum then at 40% for

earnings over £34,371 per annum and over £150,000 at 50% National Insurance Number: If you need a National Insurance number this can be obtained from the

Benefits Agency, to make enquiries contact tel: 0191 2204222. Sickness Any sickness over three days must be covered by a self-certification

note, which can be obtained from your manager, and any sickness for more than seven days must be covered by a Doctor’s certificate

IMPORTANT

List of Common Abbreviations Used On The ESR Payslip

Abbreviation Description

ARRS Arrears Payment

EN Enhancement Payment (eg. Unsocial)

OT Overtime Payment (e.g. Saturday)

NNI Payment Not Subject to NI Contributions

NP Non-Pensionable

NT Payment Not Subject to Income Tax

NW Payment not subject to Working Time Directive

OMP Occupational Maternity Pay OSP Occupational Sick Pay R Refund

SMP Statutory Maternity Pay SSP Statutory Sick Pay

WTD Working Time Directive

Please quote your assignment number on all correspondence, or w hen telephoning the Paymaster Section. This

number can be found in the top left hand corner of your payslip.



INTRODUCTION TO YOUR ESR PAYSLIP

The introduction of the Electronic Staff Record has resulted in a change to how you payslip will look. The example below (Mr Other who works on Cherry Ward) has been produced to describe what the different areas of the payslip mean. In addition, there is a small table of abbreviations on the back of the document that will help your understanding of some of the items that will appear on your actual payslip.

MR A N OTHER Surgical – Cherry Ward

ASSIGNMENT NUMBER

12345678

EMPLOYEE NAME

MR A N OTHER LOCATION

DGH DEPARTMENT

CHERRY W ARD JOB TITLE

Nurses Band 5 – Cherry W ard PAYSCALE DESCRIPTION

Rev iew Body Band 5

SAL/WAGE

23208.00

INC.DATE

01 OCT 2005

STANDARD HRS

19 PT SAL/WAGE

11758.72 TAX OFFICE NAME

HM Collec tor TAX OFFICE REF

TAX CODE

496L CUMUL NI NUMBER

AB123456T PAY AND ALLOWANCE (- = MINUS AMOUNT) DEDUCTIONS (R INDICATES REFUND)

DESCRIPTION

WKD/EARNED PAID/DUE RATE AMOUNT DESCRIPTION AMOUNT BALANCE C/F

Basic Pay Basic Pay Arrs Bank Holiday EN Arrs Night Duty EN Night Duty EN Arrs Saturday EN Arrs Sunday EN Arrs Unsocial EN Unsocial EN Arrs WTD Pay OSP Av erage Pay Arrs

86.06

49.50

4.50

86.06

14.85

1.35

11.8689

11.8689

11.8689

1021.43

232.48 3.27

176.25 8.34 9.42

18.57 16.02

2.73 26.81

1.47

PAYE NI D Pension Car Park VAT Car Parking Staff Lottery

201.52 103.40

91.01 0.65 3.69 1.00

Year to date balances (This employment only) This Payslip Summary GROSS PAY 7638.84

NI LETTER D

TAXABLE PAY 7180.50

TAX PAID 907.50

PREVIOUS TAXABLE PAY 0.00

PREVIOUS TAX PAID 0.00

PENSION CONTS 458.34

EMPLOYEE NO. 12345678

PENSIONABLE PAY 1516.79

TAX PERIOD 6

FREQUENCY M onthly

PERIOD END DATE 30 SEP 2005

PAY DATE 23 SEP 2005

PAY METHOD BACS

TAXABLE PAY 1425.78

NON-TAXABLE PAY 0.00

TOTAL PAYMENTS 1516.79

TOTAL DEDUCTIONS 401.27

NI PAY

7638.84 NI CONTS

482.96

OTHER NI PAY

OTHER NI CONTS

PENSIONABLE PAY 7638.84 SD REF NUMBER

NET PAY 1115.52

Incremental Date Shows the date of your nex t

increment or when you reached the max imum point

Assignment Number:

Uses the first 8 digits of your Employee number. If you have more than one post, these will be indicated by the

addition of -2 or -3

Salar y/Wage This box shows the actual

salary paid. The amount will be pro-rata for part-time staff.

Tax & NI Information Useful information that you may need if you have to contact your

tax office for any reason Standar d Hour s

The number of hours you are contracted to work.

Payscale Descr iption The Payscale that you are

currently paid on

Net Pay

The amount of pay that w ill be

transferred to y our Bank Account.

Pay & Allowances Monies that you are entitled to receive will

be shown here. Payments in addition to Basic Pay will usually relate to the period

that you have just worked.

The example here shows allowances paid, but also arrears paid (Arrs at the

end) following assimilation to Agenda for Change for example.

Deductions

Your total earnings w ill be assessed each period and any resulting

statutory and/or voluntary recoveries

w ill be show n here. This ex ample show s a deduction

made for entry into the Staff Lottery .

This Period Summary This section provides details

relating to your current payment. Totals of payments and

deductions are shown together with details about the pay period itself and when you can ex pect

your Net Pay to be paid.

Year to Date Balances This area shows totals for income tax

(including details from previous employment), national insurance and

pension from the beginning of the tax-year (April - Week1 or Month1), up to and

including the current pay period.

Salar y/Wage This box shows the full time salary paid

Employee Number:

This is an important identifier and should be quoted in all pay related

queries and correspondence y ou may hav e.



SMART Parking (Salary sacrifice car park deductions) From 1st January 2011 the Trust is introducing SMART Parking; it enables you to take advantage of the tax, pension and NIC breaks which reduce the cost of your permit. If you choose to pay by salary sacrifice your basic pay will be reduced and therefore the terms and conditions under your Contract of Employment will be varied. Therefore you need to understand the Terms and Conditions prior to signing the form to instruct payroll to change your normal pay deduction with no savings, to SMART reductions involving salary sacrifice and tax, national insurance and pension breaks. If you wish to change to SMART parking please complete the form at the end of this section and forward to - the ESR Payroll Department, Old Ripon Ward, JCUH. How do the savings work? The cost of the full time permit is £202.20 per annum; therefore basic pay is reduced by £202.30 per annum. The permit reduction of £16.85 gross per month is reduced by 35% (typical) net, due to the reduction in tax, contracted out national insurance and pension contributions. Therefore the net amount paid is £10.95 (2012/2013) Terms and Conditions (In addition to Car Park terms and conditions)

This Agreement is an amendment to your Contract of Employment, referring in particular to your monthly basic pay, which will be reduced by the financial value of a car parking permit. This will be your SMART adjustment. Any change in value will be notified to you in advance by Trust briefing and your SMART adjustment will be revised accordingly. You are unable to enter into SMART Benefits for parking if your chosen reduction in pay would reduce your basic pay below the National Minimum Wage or Lower Earning Limit for National Insurance purposes. You agree that in exchange for a parking permit the Trust will reduce your basic pay by the value of your chosen parking permit. This will be known as your SMART adjustment.

The Agreement will commence on the first day of the calendar month following receipt of the Parking Permit form in ESR Payroll Department The Agreement will run until 31 December. You will automatically be provided with a new permit on 1 January unless you opt out of the arrangement at this point. If you wish to opt out of the SMART parking arrangements you must inform ESR Payroll department prior to 1 January. You will then be opted out of the arrangement effective from 1 January.

The Agreement may only be terminated during the Period with the prior acceptance of the Trust. You will be permitted to review your participation in SMART Parking if you have a change of circumstances. The opportunity to come out of the scheme is not automatic and will be subject to authorisation. In order to terminate your SMART adjustment please submit a new car parking agreement form, indicating that you no longer wish to take part in SMART Parking, to ESR Payroll Department. Subject to authorisation, this will be processed from the first day of the calendar month following receipt of the new parking agreement form. In the event that this Agreement is terminated at your request, any option to enter a further SMART Parking agreement will be offered solely at the discretion of the Trust.



You agree to accept the car parking permit provided by the Trust in respect of this Agreement and agree that the permit is for your sole use. You may not exchange received permits with any person or organisation, including but not limited to the Trust, for cash, salary or any goods or services. You accept and agree that it is your responsibility to determine and understand the effect on your financial position by entering into this Agreement in respect of Trust, Pension, Redundancy or State Benefits. In entering into this Agreement you confirm your understanding that the car parking permit is solely for your personal use. For staff intending to take maternity leave please discuss your options with your payroll clerk at the earliest opportunity. Please be aware that this is a salary sacrifice agreement which can impact on various other

payments based on your basic pay, such as redundancy, pension and maternity pay. SMART Salary Parking Permits

CAR PARKING PERMITS

Opt in form

Employer

South Tees Hospitals NHS Foundation Trust (“the Trust”)

Carillion PLC

Region

Other

Employee’s Name

Home address

Payroll Number Ward Ex./bleep

Car Registration No. Make

Car 2 Make

Number of Hours worked per week ------------------------------------------

Car Park charges by Normal Payroll Deduction (tick box)

Car Park charges by Salary Sacrifice (SMART) (tick box) please refer to notes 15-24 (South Tees

Staff Only)

PLEASE READ THE TERMS AND CONDITIONS OVER THE PAGE

Declaration



I sign to agree and abide by the terms and conditions set out in the car parking scheme WITHOUT SMART benefits.

Signed: ……………………………………………….. Date: …………………………………………… Declaration by Salary Sacrifice

By signing below you agree to the variation in terms and conditions of your employment described in the Terms and Conditions and you agree to abide by the conditions of the WITH SMART B enefits

arrangement. You hereby authorise the Trust to reduce your salary accordingly and in the event of leaving the Trust to adjust any excess or outstanding car parking permits from your final net salary.

Signed: ……………………………………………….. Date: ……………………………………………

OFFICE USE ONLY PERMIT NUMBER ------------------------------------------- DATE SENT TO PAYROLL OFFICE---------------

RECEIPT NO. ------------------------------------------------ £---------------------------EXPIRY DATE ----------------

INPUT BY -----------------------------

Payroll office check salary sacrifice minimum wage -------------------------- Terms and Conditions

1. I agree to pay the car parking charges as set out by the Trust, and to have the payment deducted from my salary or to pay the fee set out for cash payers.

2. I agree if I lose my permit/sticker I will pay a £10.00 replacement charge

3. I agree that if I register two cars into the scheme I will transfer the permit to the car I am bringing onto site

4. I agree to only park in designated car parks for staff, and will not park in the Visitors car park.

5. I agree to park in a designated car parking space, displaying my permit and not on yellow or red lines, if I am

found to be parking illegally or not in a space I understand I may be liable for a fixed penalty notice, and agree to pay the fee in the given timescale

6. I understand that because I am a member of the car parking scheme I will not be guaranteed a car parking

space.

7. The Trust will not be liable for any damage to cars that are brought onto site; I agree that my vehicle(s) are brought onto site at my own risk.

8. I agree to move my car if instructed by the Security Department or the Travel Link Department.

9. I agree to display my car parking sicker/permit at all times when I am on site.

10. I agree that I will let the Travel Link Department know of any changes in details, work, personal and car

details.

11. I agree that when I leave my employment with the Trust I will return my car parking permit and sticker, I understand that the day I return my permit and sticker my payments will be suspended.

12. If payments cannot be taken from my salary, I agree to pay the relevant charge and re -new my permit if

necessary before the expiry date.

13. I understand South Tees Hospitals NHS Foundation Trust is a no smoking site, and agree to comply with the policy and not to smoke in my vehicle when I am on Trust premises.

14. I understand that not complying with the Terms and Conditions set out in the car parking scheme could result

in my Divisional/Directorate manage being informed and disciplinary action could be taken against me.



The following conditions only apply to those individuals who have taken part in SMART Parking. Only South Tees staff can take part in SMART Parking:

15. SMART - This Agreement is an amendment to your Contract of Employment, referring in particular to your

monthly salary, which will be reduced by the financial value of a car parking permit. This is known as your SMART Adjustment. Any change in value will be notified to you in advance by Trust briefing and your SMART adjustment will be revised accordingly.

16. You are unable to enter into SMART Benefits for parking if your chosen reduction in salary would reduce your

salary below the National Minimum Wage. 17. You agree that in exchange for a parking permit the Trust will reduce your core salary by the value of your

chosen parking permit. This will be known as your SMART Adjustment. 18. The Agreement will commence from the first day of the month following your applicati on to take part in

SMART Parking. 19. The Agreement may only be terminated during the Period with the prior acceptance of the Trust. You will be

permitted to review your participation in SMART Parking if you have a change of circumstances. The opportunity to come out of the scheme is not autom atic and will be subject to authorisation.

20. In order to apply for your SMART adjustment to be cancelled, please submit a new car parking agreement

form which requests that your Parking permit is paid for via salary deduction from net pay. This will be processed from the first available payroll period after authorization of your application to exit your SMART agreement.

21. In the event that this Agreement is terminated at your request, any option to enter a further SMART agreement

for the provision of a car parking permit will be offered solely at the discretion of the Trust. 22. You agree to accept the car parking permit provided by the Trust in respect of this Agreement and agree that

the permit is for your sole use. You may not exchange received permits with any person or organisation, including but not limited to the Trust, for cash, salary or any goods or services.

23. You accept and agree that it is your responsibility to determine and understand the effect on your financial

position by entering into this Agreement in respect of Trust or State Benefits. 24. In entering into this Agreement you confirm your understanding that the car parking permit is solely for your

personal use.

You accept that if you leave the Trust’s employment any outstanding amounts due to the Trust regarding the cost of the car parking permit will be deducted from your final net pay



SMART Benefits – General Q&A’s

Will my employment related benefits be affected by participation in SMART Benefits?

SMART Benefits involves a reduction to your contractual basic pay equal to the cost of your Benefits. Your pre-SMART Benefits salary (that is your gross pay before taking into account the SMART Benefits reduction) will be known as your ‘Basic Pay’.

Your Basic Pay (pre-SMART Benefits salary) will be referred to in the undernoted circumstances to ensure your employment related benefits are not adversely affected by SMART benefits:

To determine pay increases;

To calculate overtime rates;

The Trust will quote your Basic Pay to Banks/Mortgage lenders when they make a request for your salary details. Banks are fully aware that arrangements such as SMART Benefits increase your take home pay and therefore increase your disposable income. SMART Benefits should not impact the amount of money that you can borrow.

Is everyone eligible for SMART Benefits?

SMART Benefits is unsuitable for a very small number of employees.

If your salary is at, or close to, the National Minimum Wage (NMW) threshold, you will not be able to participate in SMART Benefits as the Trust cannot reduce your contractual hourly rate of pay

below the NMW threshold.

Will there be any changes on my payslip?

Yes. Your payslip entries will be changed slightly to accommodate SMART Benefits.

Will SMART Benefits affect my entitlement to receive state-related benefits such as State

Pension or unemployment benefits?

No because you cannot enter into a SMART Benefits arrangement if the reduction would take you below the threshold at which you pay NICs. Therefore, if you are allowed to enter into a SMART Benefits arrangement it means your pay is at a sufficient level to continue paying NICs and so

your state related benefits should not be affected.

Will SMART Benefits affect my pension entitlement?

Yes if you are within 3 years of retirement, or 10 years if on the 2008 pension scheme, your

pension will be reduced as pension is calculated on your final salary after the SMART reduction

Will SMART Benefits reduce my statutory maternity, paternity or adoption pay?

Under SMART Benefits you will be entitled to a lower amount of Statutory SMP/SPP/SAP. This is because your statutory entitlement is linked to your lower post SMART Benefits salary and not your Basic Pay. If you want to ensure these Statutory benefits are not affected you could opt out of SMART Benefits in the pay period before that which is used to calculate your Statutory benefits. However, in doing this you would lose the advantages of SMART Benefits for this

period.

If you have further queries on this matter please contact ESR Payroll.

Will SMART Benefits reduce my statutory sick pay?

No because you cannot enter into a SMART Benefits arrangement if the reduction would take you below the threshold at which you pay NICs. Therefore, if you are allowed to enter into a SMART



Benefits arrangement it means your pay is at a sufficient level to continue paying NICs and so your state related benefits should not be affected.

Will SMART Benefits impact Tax Credits?

Working Tax Credit (WTC) is calculated on actual taxable earnings, so if you enter SMART

Benefits your WTC entitlement may increase.

Each family situation is unique, therefore you should always take advice regarding Working Tax Credits and its Childcare Element. The Tax Credits website is: http://www.hmrc.gov.uk/taxcredits Will SMART Benefits impact Incapacity Benefit/ Jobseeker’s Allowance (JSA)

No because you cannot enter into a SMART Benefits arrangement if the reduction would take you below the threshold at which you pay NICs. Therefore, if you are allowed to enter into a SMART Benefits arrangement it means your pay is at a sufficient level to continue paying NICs and so

your state related benefits should not be affected.

Will SMART Benefits affect my Student Loan repayments?

If you have a Student Loan and earn over £1250 per month repayments will be deducted from your salary. This is based on your salary after SMART Benefits (not your Basic Pay) and therefore you could see your repayments reduce or stop altogether as a result of taking part in

SMART Benefits.

What happens if I go on Unpaid Leave or take a Career Break?

You will be required to make alternative arrangements to pay for the benefit or return the item,

please check your signed agreement.

What if I change from full-time to part-time working during the year, or vice versa?

This would be regarded as a change of circumstances. You would be permitted to review your benefits and it may be possible to come out of the scheme after discussion with ERS Payroll. The

opportunity to come out of the scheme is not automatic and will be subject to authorisation.

What happens if I leave employment?

ERS Payroll will write to you prior to your leaving date, setting out all your options in respect of

your benefits package.

http://www.hmrc.gov.uk/taxcredits



NHS PENSION SCHEME

All employees between 16 and 75 are eligible to join the NHS Pension Scheme, except those returning on flexi retirement and those already employed in a whole time post elsewhere. All new employees are automatically put into the NHS Pension Scheme. This will cost between 5% and 10.9% of your salary before deduction of income tax. (There will be changes from 1.4.2013) You will pay a lower rate of National Insurance contributions, so the real cost is approx 3% to 4.5% of your pensionable pay. The NHS contributes a further 14% to your pension. If you do not wish to be in the pension scheme you should complete form SD502. From day one

If you should die before retirement, the scheme will pay out a cash sum equal to 2 years pensionable/reckonable pay. This is normally paid to your surviving spouse/civil partner. If you are not married/in a civil partnership you should consider nominating a beneficiary (Form DB2). If you leave, the value of the benefits you have built up may be transferred to another pension arrangement or, if you have less than 2 years membership, you can apply for a refund of contributions (Form RF12) It is also possible to buy extra pension in order to increase your benefits at retirement. After 2 years

If you were to become too ill to work, you could, if approved, take your pension early. After 5 years

If you were to be made redundant at age 50 or more in the 1995 scheme, age 55 in the 2008 scheme, you could receive a pension and a cash lump sum. On retirement – age 60 in 1995 scheme, age 65 in 2008 scheme On retirement you will receive a pension for life based on your earnings and length of scheme membership. In the 1995 scheme you will also receive a tax-free lump sum. There is no guaranteed lump sum in the 2008 scheme, but members can give up part of their pension in exchange for cash. After the age of 55, the pension is increased annually in line with the CPI. Your surviving spouse/civil partner will receive a pension after your death. If you are not married but have a long term partner, you can nominate that partner to receive a survivor’s pension after your death. (form PN1). All forms can be downloaded from www.nhsbsa.nhs.uk Auto enrolment 1.4.2013 From this date all eligible staff must be enrolled into a pension scheme every three years. The NHS choice is the NHS pension scheme, if you do not fit the criteria for this scheme an alternative scheme, NEST, is available. You still retain the option to opt out of either scheme.

http://www.nhsbsa.nhs.uk/



Date:

The James Cook University Hospital

Marton Road

Middlesbrough

TS4 3BW

Dear Important information

The government introduced a new law on 1st October 2012 which requires employers to enrol workers into a workplace pension scheme, even if they have previously opted out. Employees will be automatically enrolled into a workplace pension scheme if they;

Are not already in one;

Earn over currently £9,440 a year (or £786 a month);

Aged 22 or over but under State Pension age. From 1st April 2013 South Tees Hospitals NHS NHS Foundation Trust must give all their staff access to a workplace pension. If you would like to find out more about auto enrolment go to http://www.nhsemployers.org and search for automatic enrolment. The majority of South Tees Hospitals NHS Foundation Trust employees are eligible to join the NHS Pension Scheme but a small number are not. Therefore, the Payroll Office require you to complete the attached form so they can assess which scheme you are entitled to join after 1st April 2013. The Payroll Office will then place you in the correct pension scheme and send you details of the scheme. In the meantime please complete the attached form and return to the Payroll office as soon as possible. If this form is not returned it may result in your salary being incorrect. Yours sincerely Lynn Biggs Lynn Biggs Payroll and Creditors Manager

http://www.nhsemployers.org/



The James Cook University Hospital

Marton Road

Middlesbrough

TS4 3BW

Auto Enrolment Questionnaire

This questionnaire captures details for South Tees Hospitals NHS Foundation Trust to assess your current eligibility for membership of the NHS Pension Scheme or the Alternative Pension Scheme. This must be completed as fully as possible and returned to the Payroll Office as soon as possible. Please return via the internal post, where possible, to; Pension Officer, Paymasters Department, JCUH.

For staff without access to the internal post, please return to Pension Officer, South Tees Hospitals NHS Trust, Paymasters Department, The James Cook University Hospital, Marton Road, Middlesbrough. TS4 3BW

Name «First_Name» «Surname»

Employer Name South Tees Hospitals NHS Foundation Trust

Job Role/Title «Role»

Assignment Number «Assignment»

Question 1

Do you currently have any other NHS post (i.e. at the same

time as this post), including Bank (but excluding agency)? Yes

No

If you have answered No go to Question 3.

Question 2

Who is your other employer?

Please indicate contract type

of other post: Full Time

Part Time

Bank

If you are part time, please state number of contract hours:

If you have answered Full Time go to Declaration.



Question 3

Have you previously been a member of the NHS Pension

Scheme and taken pension benefits (i.e. Retirement - Early

or Age, Early Retirement, Ill Health Retirement or other type

of NHS Pension)?

Yes

No

If you have answered No go to Declaration.

Which NHS Retirement

Benefit you are in receipt of: Ill Health

Redundancy

Retirement

Which scheme you were

a member of: 1995 Scheme

2008 Scheme

Not Known

Date the NHS Retirement

Benefits started:

Declaration

I confirm that I have completed the above form to the best of my ability and knowledge and undertake to advise my payroll team in the event that I should alter the position stated above in respect of employment with any other NHS organisations.

Signature:

Date:



INFECTION PREVENTION AND CONTROL AND HEALTHCARE ASSOCIATED INFECTIONS

The infection prevention and control team provides a service to all patients, carers, visitors and staff in the Trust. This includes hospitals, clinics, community hospitals and patients’ homes. Though the aim is to prevent and control infections in hospital and other locations where healthcare is provided, we also provide advice and act as a resource on all infection prevention and control issues to promote a safe environment for all in contact with healthcare facilities and providers. Contact details:

South Tees Hospitals NHS Foundation Trust -The James Cook University and Friarage hospital sites: 01642 854800 Middlesbrough and Redcar & Cleveland Community locality: 01287 284456 Hambleton and Richmondshire community locality: 01845 573917

The following information contains the nationally and trust agreed standard principles of infection prevention and control that must be followed by all staff at all times:

Hospital wards and departments

The hospital environment must be visibly clean, free from dust and soilage and acceptable to

patients, their visitors and staff.

Where a piece of equipment is used for more than one patient, (e.g. commode, bath hoist) appropriate decontamination using the correct products must follow each and every episode of use.

Statutory requirements must be met in relation to the safe disposal of clinical waste, laundry arrangements for used and infected linen, food hygiene and pest control.

All staff involved in hospital hygiene activities must be included in education and training related to the prevention of healthcare-associated infection.

HANDS

Hands that are visibly soiled or potentially grossly contaminated with dirt or organic material must be washed with liquid soap and water.

Hands must be decontaminated immediately before each and every episode of direct patient contact / care that involves direct contact with patients’ skin, their food, invasive devices or dressings and after any activity or contact that potentially results in hands becoming contaminated. For practical purposes this means that hands must be decontaminated before and after entering any patient’s personal bed area.

Hands should be decontaminated between caring for different patients, or between different caring activities. Unless visibly soiled, an alcohol based hand rub. Be aware that alcohol gel is not effective against Norwalk-like viruses or Clostridium difficile spores. In these instances, soap and water must always be used.

Remove all wrist and hand jewelry (with the exception of a single wedding band as specified in HIC 14: hand hygiene) at the beginning of each clinical shift before regular hand decontamination begins. Cuts and abrasions must be covered with waterproof dressings.



Effective handwashing technique involves four stages: preparation, washing, rinsing, and

drying. Washing requires wetting hands under tepid running water before applying liquid soap. The handwash solution must come into contact with all surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 10-15 seconds, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Hands should be rinsed thoroughly prior to drying with good quality paper towels. N.B. If a wedding band is worn, ensure that the area under the ring is decontaminated by moving the ring and cleaning beneath it.

When decontaminating hands using alcohol hand rub, hands should be free of dirt and organic material. The hand rub solution must come into contact with all surfaces of the hand. The hands must be rubbed together vigorously, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers, and until the solution has evaporated and the hands are dry.

Apply an emollient hand cream at the end of each shift to protect skin from the drying effects

of regular hand decontamination. If a particular soap, antimicrobial handwash or alcohol product causes skin irritation seek occupational health advice.

GLOVES

Gloves must be worn for invasive procedures, contact with non-intact skin, mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions and excretions; and when handling sharp or contaminated instruments.

Where gloves are worn as above, they should be put on immediately before an episode of patient contact or treatment and removed as soon as the activity is completed. Hands should be decontaminated immediately before wearing gloves. Staff members should change gloves and decontaminate hands between caring for different patients, or between different care/treatment activities for the same patient.

Gloves must be disposed of as clinical waste and hands should be decontaminated following the removal of gloves. If the gloves were worn because of contact with a patient in isolation (or his or her environment) then the hands should be washed with soap and water after removal of the gloves. This is because alcohol gel is ineffective against certain organisms for which patients are isolated (C. difficile and norovirus).

Gloves conforming to European Community (CE) Standards and of an acceptable quality must be available in all clinical areas.

Latex gloves should be avoided where suitable alternatives exist.

Neither powdered nor polythene gloves should be used in healthcare activities.

Gloves should also be worn by staff in contact with the environment of a person requiring source isolation. Gloves are required for any staff member entering the isolation room. If a side room was not available then gloves must still be worn to enter the patient’s bed area.

APRONS

Disposable plastic aprons must be worn whenever there is a risk that clothing or uniforms

may become exposed to blood, body fluids, secretions and excretions, with the exception of



sweat. This includes for routine bed-making. They must also be worn when coming into contact with the environment of a patient who is being isolated for any reason, even if the patient is being nursed in a bay if a single room is not available. If the patient is in a single room or isolated in the bay, then the apron must be worn to enter the room or bed area.

Plastic aprons must be worn as single use items for a procedure or single episode of patient care and then disposed of as clinical waste.

Full body repellent gowns should be worn where there is a risk of extensive splashing of blood, body fluids, secretions and excretions, with the exception of sweat, onto the skin of healthcare practitioners.

FACE, EYE AND RESPIRATORY PROTECTION

Face masks and eye protection (e.g. goggles or visors) should be worn where there is a risk

of blood, body fluids, secretions and excretions splashing into the face and eyes.

Appropriate respiratory protective equipment must be used when directed by the infection prevention and control team or when indicated in the relevant infection control policy. This can include influenza and measles. Please seek Infection Prevention and Control advice when caring for these patients.

SHARPS

Sharps must not be passed directly from hand to hand and handling should be kept to a

minimum.

The sharps container must be taken to the patients point of care when using needles

Needles must not be bent or broken prior to use or disposal.

Needles and syringes must not be disassembled by hand prior to disposal.

Needles must not be re-sheathed.

Single use vacutainer barrels must be used. Once a sharps container is full, secure the container and record the name and date of closure

on the container.



LOCAL COUNTER FRAUD SERVICE

An Introduction to the Local Counter Fraud

Service



An Introduction to NHS Economic Crime Counter Measures

What is the Problem?

Fraud now costs the UK economy an estimated £73 billion. Losses to the public purse account for about a third of the figure quoted. It shows year on year increases. Most organisations face greater crime risks as a result. The NHS is no different. NHS fraud is still committed by a relatively small minority of staff, patients or contractors. It does have a significant financial impact though. Offences are also regularly detected. Many involve six figure sums, diverted illegally from patient care. Fraudulent actions can also sometimes pose further clinical risks. Some very recent cases include:

A Mental Health Nurse who failed to disclose during the recruitment process that he had been dismissed from a previous employment pleaded guilty to three counts of fraud by false representation and one count of fraud by failing to disclose information. He was sentenced to 10 months imprisonment

A Hospital Pharmacy Technician who fraudulently entered information on a Hospital system regarding the dispensing of items to patients, including patients who were deceased pleaded guilty to one count of fraud by abuse of position. She was sentenced to 8 months imprisonment suspended for 2 years, a 2 year supervision order and instructed to complete 120 hours of unpaid work.

The Trust also has to satisfy statutory requirements placed on all UK organisations, by ensuring it has adequate mechanisms in place to deal with bribery and corruption threats. More information about NHS criminal cases and action taken can be accessed by undertaking the Trust’s e-learning fraud, bribery and corruption module. Key Definitions

Fraud usually involves some kind of dishonest misrepresentation to unfairly gain a financial kind of benefit or an advantage.

It can be committed if job applicants deliberately lie on their application forms about

qualifications held, employment history or right to work in the UK. Fraud can also be committed

if employees make false claims for overtime, travel expenses, other allowances or work

elsewhere during substantive Trust hours or whilst absent on sickness leave.

The Bribery Act defines other unacceptable behaviours.

It means we must also maintain the upmost integrity if we come into contact with external

parties via work. Impropriety does not have to involve cash or actual payment exchanging

hands. It can take many forms such as accepting undeclared gifts, lavish treatment or tickets to

events from those seeking to contract with the Trust.

NHS bribery and corruption might include being offered inducements for the following reasons:

To unfairly secure or keep an employment or commercial contract / or an order for the supply of



goods or services and whilst gaining any competitive advantage over a competitor

To inappropriately or recklessly turn a blind eye to a patient health / safety issue

To irresponsibly collude and conceal poor contractor performance either by allowing invoiced

substitution or supply of inferior materials or the inclusion of false / inflated labour charges

The Trust’s e-learning module on fraud, bribery and corruption also provides a more detailed oversight on NHS economic crime categories and trends. What is in Place?

The Trust takes coordinated and systemic steps to deter fraudsters and manage its exposure to fraud, bribery and corruption. The proactive elements of this approach help to ensure that valuable local NHS resources are adequately protected.

Step one involves carrying out an organisational risk assessment. It highlights areas at the Trust which are more vulnerable to fraud, bribery and corruption. This forms the basis of the Trust’s intelligence led Anti Fraud, Bribery and Corruption Work Plan; monitored by the Finance Director. It allows well intentioned work to be targeted proportionately.

The Trust purchases a balanced Local Counter Fraud Service from Audit North to facilitate its

anti crime work streams. Activities range from discreetly conducting sensitive enquires into suspected fraud, bribery or corruption to carrying out Trust system reviews and preventing / detecting crime at the earliest stage.

Awareness raising work is also carried out continuously, throughout the year; to embed an

effective anti fraud culture at the Trust – links to the Audit North newsletter are published periodically throughout the year, it contains articles and blogs on fraud issues.

The Local Counter Fraud Service shares information lawfully with Human Resources and Internal Audit to achieve strategic aims to reduce fraud, bribery corruption to an absolute minimum. We also work closely with NHS Protect. NHS Protect provides national policy direction for all health related anti crime work. It also leads on quality assuring anti crime performance standards & making enquiries into exceptionally serious cases; via its National Investigation Service (NIS). Further details about Audit North’s ‘not for profit,’ anti crime services; together with our risk themed and tailored communications, can be found at: www.auditnorth.co.uk

What does my role have to do with countering fraud?

Everyone has an important role to play in countering fraud, bribery and corruption, whilst at work; The most immediate priority is simple and straightforward for any professional work force: All staff should familiarise themselves with the respective codes of conduct that apply to their areas of work. They must always follow financial procedure notes set by the Trust Management Team. Line management advice should always be sought first, if staff members encounter difficulty understanding any rules that apply to them. These principles apply at all levels and in all circumstances regardless of whether we complete mileage claim forms or have responsibilities for complex tender exercises. Managers should pay particular attention to promptly processing for all contract variations or leavers documentation to prevent unnecessary payroll risks or problems. All staff members will gradually receive more information about the type of wider and more extensive fraud



indicators that could affect the Trust. The e-learning package has been developed to provide a general awareness taster, supported progressively by articles and blogs on fraud issues contained within the periodic Audit North newsletter. We also immediately issue to relevant staff alerts relating to live fraud threats. Staff and their Managers working in higher risk areas will also periodically receive some more in depth intelligence bulletins / notices / presentations; as a pre-requisite to detailed systems review. This will enable them; in partnership with the Local Counter Fraud Service, to play a much fuller role in crime prevention work. What am I expected to do to help?

All employees are empowered to contact the Local Counter Fraud Service about any specific concerns, or if they are concerned that their area of work may be potentially susceptible to fraud, bribery and corruption. Dialogue with the Local Counter Fraud Service might also involve referring any system controls weaknesses, as well as the potentially fraudulent actions of NHS staff, patients or contractors; if the need arises.

Staff must never feel that they have to prove allegations, but should always act in good faith.

They should never seek to investigate or fix matters themselves. Fraud, bribery or corruption risk referrals must always be managed by members of the Local Counter Fraud Service. This is because they have undertaken specialist training that equips them to carry out these tasks robustly, but fairly. All issues reported to the Local Counter Fraud Service will be handled confidentially.

Participation by all staff members in regular Trust anti crime surveys is also particularly valued.

This is because it provides clear feedback on vital work undertaken to safeguard our resources; plus additional means for everyone to realistically influence or shape the design / direction of our future efforts.

Staff undertaking Trust induction training may also be sent an electronic questionnaire, in due course. This will also provide further opportunity to give feedback; following completion of the Trust’s e-learning module on fraud, bribery and corruption

All newly inducted Trust staff members are recommended to initially complete the Trust’s e -

learning module on fraud, bribery and corruption, if they wish to contribute constructively and effectively to the organisation’s anti crime work

Local Counter Fraud Service (LCFS)- Contact Details:

The team at Audit North is committed to delivering its work to high professional standards possess extensive prior operational experience.

[email protected] or 0191 4415939

[email protected] or 0191 4415918

A member of the team also takes on more precise responsibilities for each client Trust; as its Lead Local Counter Fraud Specialist (LCFS). LCFS’s are accredited and vetted by NHS Protect to carry out anti crime work within the health economy. The Lead LCFS at South Tees Hospitals NHS Foundation Trust is Graham Thompson. Staff members are also encouraged to use other secure / equally supportive fraud, bribery and corruption referral options, including completing a referral form and forwarding it to the LCFS or reporting any issues to the NHS Protect; ‘Fraud and Corruption Reporting Line’ – 0800 028 40 60 or www.reportnhsfraud.nhs.uk These alternatives are to be found within the Trust’s Anti Fraud and Whistle-blowing Polices.

Updated March 2014



INFORMATION GOVERNANCE

Information governance allows organisations and individuals to ensure that personal information is handled legally, securely, efficiently and effectively, in order to deliver the best possible care. It additionally enables organisations to put in place procedures and processes for their corporate information that support the efficient location and retrieval of corporate records where and when needed, in particular to meet requests for information and assist compliance with corporate governance standards. Information governance provides a consistent way for employees to handle personal, confidential and sensitive information in a legal, secure, efficient and effective manner in order to deliver the best possible care for patients. Information governance is underpinned by several policies which are available on the trust Intranet site. Please ensure you have read all the IG policies and that you are particularly familiar with the following: REF N0. Name and Link

G100 Overarching Information Governance Policy

IG101 Data Protection Policy

IG102 Public Access to Corporate Information Policy

IG103 Information Risk Management Policy

IG104 Information Security Policy

IG105 Email & Internet Policy

IG106 Transfer for Person Identifiable, Confidential, or Sensitive Information Policy

IG107 Registration Authority Policy

IG109 Mobile Working Policy

IG110 Encryption Policy

IG112 Access Control Policy

IG113 Records Management Policy

The Trust information governance intranet site also contains a lot of other guidance documents which you may find useful. An employee’s responsibility for information governance includes:

Ensuring that confidential information is not unlawfully or inappropriately accessed

Do not share your computer password with anyone. Make sure you log out when you finish using the computer. Do not leave paper records unattended. Lock rooms and cupboards where personal information is stored.

http://clinicalgov/policies/INFORMATION%20GOVERNANCE/Overarching%20Information%20Governance%20Policy%20-%20IG100.doc

http://clinicalgov/policies/INFORMATION%20GOVERNANCE/Data%20Protection,%20Confidentiality%20&%20Disclosure%20Policy%20-%20IG101.doc

http://clinicalgov/policies/INFORMATION%20GOVERNANCE/Public%20Access%20to%20Corporate%20Information%20Policy%20IG102.doc

http://clinicalgov/policies/INFORMATION%20GOVERNANCE/Information%20Risk%20Policy%20-%20IG103.doc

http://clinicalgov/policies/INFORMATION%20GOVERNANCE/Information%20Security%20Policy%20-%20IG104.doc

http://clinicalgov/policies/INFORMATION%20GOVERNANCE/Email%20&%20%20Internet%20Policy%20-%20IG105.doc

http://clinicalgov/policies/INFORMATION%20GOVERNANCE/Transfer%20for%20Person%20Identifiable,%20Confidential%20or%20Sensitive%20Information%20Policy%20-%20IG106.doc

http://clinicalgov/policies/INFORMATION%20GOVERNANCE/Registration%20Authority%20Policy%20-%20IG107.doc

http://clinicalgov/policies/INFORMATION%20GOVERNANCE/Mobile%20Working%20Policy%20-%20IG109.doc

http://clinicalgov/policies/INFORMATION%20GOVERNANCE/EncryptionPolicy%20-%20IG10.doc

http://clinicalgov/policies/INFORMATION%20GOVERNANCE/Access%20Control%20Policy%20-%20IG112.doc

http://clinicalgov/policies/INFORMATION%20GOVERNANCE/Records%20Management%20Policyv3%20-%20IG113.doc



Disclosing personal information only to those who legitimately need to know to carry out their role

Ensure that you are not overheard when discussing personal information about clients and do not discuss clients in public areas. Informing patients/clients of the reason that their information is being collected

The Data Protection Act 1998 states that information is obtained lawfully and fairly if individuals are informed of the reason that their information is required, what will be done with their information and who it is likely to be shared with. Patients should be informed it their information is likely to be used for research so that they have the option to opt out. Ensuring that the information that is recorded is accurate, legible and complete and has been verified by the patient if possible

Patients should be given the opportunity to check information about them to allow them to point out any corrections that need to be made. Quality of data is very important to the Trust and facilitates efficient patient care. Ensuring you comply with procedures and standards for the creation and filing of records and documents

The Trust needs to be able to locate and retrieve information efficiently Sharing personal information appropriately and lawfully

You must obtain consent before sharing personal information with others, for example if a patient requires referral to another agency. Information governance enquiries/advice email: [email protected] DATA PROTECTION PRINCIPLES - A GUIDE FOR STAFF 1. FIRST PRINCIPLE

“Personal data shall be processed fairly and lawfully and, in particular, shall not be processed unless – at least one of the conditions in Schedule 2 is met, and in the case of sensitive personal data, at least one of the conditions in Schedule 3 is also met.”

2. SECOND PRINCIPLE “Personal data shall be obtained only for one or more specified and lawful purposes, and

shall not be further processed in any manner incompatible with that purpose or those purposes.

3. THIRD PRINCIPLE

“Personal data shall be adequate, relevant and not excessive in relation to the purpose or purposes for which they are processed.”

4. FOURTH PRINCIPLE

“Personal data shall be accurate and, where necessary, kept up to date” 5. FIFTH PRINCIPLE

“Personal data processed for any purpose or purposes shall not b kept for longer than is necessary for that purpose of those purposes.

6. SIXTH PRINCIPLE

“Personal data shall be processed in accordance with the rights of data subjects under this Act”




7. SEVENTH PRINICPLE “Appropriate technical and organisational measures shall be taken against unauthorised

or unlawful processing of personal data and against accidental loss or destruction of, or damage to, personal data.”

8. EIGHTH PRINCIPLE

“Personal data shall not be transferred to a country or territory outside the European Economic Area, unless that country or territory ensures an adequate level of protection for the rights and freedoms of data subjects in relation to the processing of personal data.”

Part of the Trust’s compliance with the DPA 1998 is to ensure that all staff have reviewed and signed an appropriate declaration, which will need to be held by your line manager within your personal file. This declaration can be found within the Data Protection Policy – Appendix B, page 36. THE INFORMATION GOVERNANCE E-LEARNING TRAINING

Annual Mandatory Information Governance training must be completed by All Staff within the organisation (including new starters, locum, temporary, student and contract staff). As an employee it is your responsibility to ensure that you have completed basic Information Governance training. To access the training modules you must use the ESR NLMS e-learning icon which you will find on the desktop of your PC or on the PCs available in the libraries on both the James Cook and Friarage sites. The modules that you need to complete are listed below. 'Introduction to Information Governance' - Please complete this module if your role involves

having access to personal information 'Information Governance - The Beginner's Guide' Please complete this module if you do not

routinely access personal information as part of your role 'Refresher Module' - All staff who have already completed one of the above IG training modules

please complete this module which will take staff less time to complete. FOR STAFF WHO CANNOT ACCESS THE ESR NLMS IG E-LEARNING: Online - On-line via the NHS Connecting for Health e-learning programme via this link Information Governance Training Tool / e-learning. This can be accessed either through

computers within work areas or in the Academic Centre at JCUH.

Please complete one of the following training modules

'Introduction to Information Governance' - Please complete this module if your role involves having access to personal information 'Information Governance - The Beginner's Guide' Please complete this module if you do not

routinely access personal information as part of your role 'Refresher Module' - All staff who have already completed one of the above IG training modules

please complete this module which will take staff less time to complete.

http://clinicalgov/policies/INFORMATION%20GOVERNANCE/Data%20Protection,%20Confidentiality%20&%20Disclosure%20Policy%20-%20IG101.doc

https://www.igte-learning.connectingforhealth.nhs.uk/igte/index.cfm



For any staff who have not registered on the Information Governance Training Tool please

access the User Guide ‘How to Register’ in the following link: Information Governance Training

Tool User Guide - How to Register

At Home - Anyone wanting to complete the IG e-learning training at home can find instructions in the following link: How to do your information governance training Delivered session facilitated by IG Divisional Lead - Attending a delivered sessions that are facilitated by a Divisional/Directorate Information Governance lead within work areas. Please contact your Information Governance lead for your division to discuss Via the contact details on the following link: Information Governance Divisional Leads Other E-Learning Training modules Relevant to Job Role - Other e-learning modules which are relevant to your job role are available for staff to complete, for access to these please click IG Role Based Training

Contact Details

Name Title Ext No.

Nicky Huntley

Head of Information Governance 54964

Steven Orley

Deputy Information Governance Manager 55732

Christine Bell

IG Specialist – Information Rights Management & Compliance

53593

Jennifer McArdle

IG Specialist – Security & Compliance 53584

Emma Taylor

IG Assistant 54910

Emma Pearsall IG Assistant

53743

Michelle Fernie

Secretarial Support, Information Governance 54291

Updated January 2013

http://stis-001/healthcare_governance/departments/information_governance/Guidance_Docs/IGTT%20User%20Guide%20-%20How%20to%20Register.doc

http://stis-001/healthcare_governance/departments/information_governance/Guidance_Docs/IGTT%20User%20Guide%20-%20How%20to%20Register.doc

http://stis-001/healthcare_governance/departments/information_governance/Guidance_Docs/how%20to%20do%20your%20information%20governance%20training.docx

http://stis-001/healthcare_governance/departments/information_governance/Guidance_Docs/IG%20Divisional%20leads.docx

http://stis-001/healthcare_governance/departments/information_governance/Guidance_Docs/IGTModulesforrole2011-12.doc

http://stis-001/healthcare_governance/departments/information_governance/Guidance_Docs/IGTModulesforrole2011-12.doc



SAFEGUARDING CHILDREN TEAM

The Trust believes that every unborn baby, child and young person has the right to grow up free from abuse or neglect. The Trust board is committed to ensuring that practitioners are enabled to act in support of the children and families they work with and to also work in partnership with local agencies where the Trust cannot provide this support alone. The board expect that at all times the needs of the child will be paramount and that whenever possible practitioners will work in partnership with families. Advice, support and safeguarding supervision is available to all members of staff should they have any concerns about the welfare of a child. Safeguarding Children Team

Murray Building James Cook University Hospital Ext 55601 Chaloner Building Church Street Guisborough (01287) 284192 Dr Rosemary Thwaites

Named Doctor Child Protection/Consultant Paediatrician

Please do not hesitate to seek advice and support should you have concerns about a child, or the child of a patient. TRAINING CQC require that all staff have safeguarding children training

Level Who How

Level 1 All non-clinical staff working in a health care setting Trust Induction 3 yearly update in CMAT

Level 2 All clinical staff who do not meet requirements for level 3 training who have any contact with children, young people and/or parents/carers

Initial 2 hour training 3 yearly update in CMAT

Level 3 Core Clinical staff in permanent position working with children young people and their carers who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and the parenting capacity where there are safeguarding concerns. This includes urgent and unscheduled care staff (inc A&E), learning disability nurses, paediatric allied health professionals, sexual health staff, obstetricians, paediatric radiologists, paediatric surgeons, paediatric anaesthetists, and paediatric dentists.

Full day (2 PA’s) level 3 training delivered by Safeguarding Children trainer Four hours (1 PA) update training in 3 years

Level 3 + Clinical staff in permanent position working with children young people and their carers who could potentially contribute to assessing, planning, intervening and

Two days (4 PA’s) level 3 education/ learning



evaluating the needs of a child or young person and the parenting capacity where there are safeguarding concerns from the following professional groups: Paediatricians, paediatric intensivists, child psychologists, GPs, children’s nurses, school nurses, midwives and health visitors

Twelve hours (3 PA) update training in 3 years

For further information on training please contact Safeguarding Children Team trainer or visit the Safeguarding Children website on the Trust intranet. Please discuss your training needs with your line manager. Training should be accessed within six months of coming into post.



SAFEGUARDING VULNERABLE ADULTS Awareness information for staff

South Tees NHS Foundation Trust is committed to safeguarding patients

All patients have the right to feel safe during their hospital stay. A patient’s ability to protect their self and safeguard their well-being will be affected by personal circumstances, risks arising from their environment, counter balanced by environmental support. South Tees Foundation Trust is committed to safeguarding all patients and providing additional measures for patients who are less able to protect themselves from harm or abuse.

A vulnerable adult is defined as ‘a person 18 years or over, who is or maybe in need of community care services by reason of mental or other disability, age or illness, and who is or maybe unable to take care of him/herself or unable to protect him/herself against significant harm or serious exploitation’ (No Secrets, Department of Health, 2000) Abuse is defined as ‘the violation of an individual’s human or civil rights by any other person(s).’ Abuse can be deliberate or unintentional and can result from either actions or omissions and identified within seven categories: physical, sexual, emotional, financial, neglect, discriminatory or institutional. Any or all types of abuse may be perpetrated as a result of deliberate intent, negligence or ignorance. (No Secrets, Department of Health, 2000) South Tees Foundation Trust safeguarding adult activity encompasses:

1. Prevention through the delivery of high quality care:

A duty of care is a requirement placed on an individual to exercise a reasonable standard of care while undertaking activities (or omissions) that could foreseeably harm others. However, duty of care also includes respecting the person’s wishes and protecting and respecting their rights. All adult patients have the right to self-determination and consent is required for any care/treatment delivered (unless treated lawfully without consent under the Mental Health Act, 1983). When caring for patients who lack the capacity to consent for care and/or treatment all trust staff are required to practice in adherence with the Mental Capacity Act (2005). Mental Capacity Act (2005) practice guidance should be available in all clinical areas. 2. Response to actual suspected abuse in adherence to locally agreed safeguarding

protocols:

All Trust staff are required to undertake Safeguarding Vulnerable Adults training appropriate to their role in order that they practice in adherence with the Trust G62 Safeguarding Vulnerable Adults Policy when suspecting abuse of a vulnerable adult through a disclosure of information or the presentation of abuse. 3. Learning to improve prevention of abuse and patient services:

Lessons learned and information obtained from safeguarding processes will allow for an understanding of how well the incident was managed, whether patient needs were met and identify wider themes and trends to guide practice and increase the prevention of abuse. Safeguarding Vulnerable Adults training requirements:

• Level 1 training - Safeguarding Adults (for all staff, required every three years) This will be

completed at Corporate Trust Induction, then via Corporate Mandatory Awareness training (delivered session) or via e-learning via the National Learning Management System (NLMS) or Trust Safeguarding training programme via specialist nurse (delivered session). • Level 2 training - Safeguarding Adults two day course for Ward / Department managers and

Clinical Matrons. (Credits awarded will be 10 Level 3 credits).



MENTAL CAPACITY ACT (2005) The Mental Capacity Act (MCA) provides a statutory framework for people who lack capacity to make decisions for them self, or people who have capacity and want to make preparations for a future time when capacity is lost. Trust employees who are involved in, or are directly responsible for, the care of someone who lacks capacity to make decisions regarding their care or treatment have a legal obligation to comply with the MCA (2005)/DOLS and associated Codes of Practice. Training requirements:

Mental Capacity Act/DOLS training (for all Clinical staff, required every three years) e-learning via the National Learning Management System (NLMS) or Trust MCA/DOLS training programme via specialist nurse.

The five principles of the MCA aim to safeguard those people in our care who need support in decision making or require a decision made in their best interest:

1. An assumption of capacity, unless otherwise evidenced. 2. All practical steps must be made to help a person make a decision. 3. A person who has capacity has the right to make an unwise decision. 4. An act done/decision made under the MCA must be done in the person’s best interest. 5. An act done/decision made must be done so in the least restrictive manner available.

The MCA (2005) s.44 introduced a criminal offence of ill treatment or wilful neglect of a person

who lacks capacity. A person found guilty of such an offence may be liable to imprisonment for a term of up to five years.

Whilst care must be delivered without restricting peoples personal freedoms wherever possible, it might in certain circumstances be necessary to deprive someone of their liberty, who lack the capacity to decide on care/treatment, in order to safeguard them from harm. There is a standard process which must be followed before a person can be deprived of their liberty. (Deprivation of liberty Safeguards, DOLS) Advice and support can be obtained by contacting:

Name Title Ext No.

Helen Williams Specialist Nurse Safeguarding Adults or on call patient safety manager via switch (out of hours)

52241



OCCUPATIONAL HEALTH DEPARTMENT INFORMATION

A CONFIDENTIAL SERVICE BASED AT SOUTH LODGE, JAMES COOK UNIVERSITY HOSPITAL AND FRIARAGE HOSPITAL

What is Occupational Health?

The occupational health team work with individuals and managers to promote and maintain the physical and psychological health and wellbeing of employees. Our aim is to ensure that individuals are fit to do the job that they are employed to do and that their work or working practices does not adversely affect their health. We are committed to providing evidence based proactive service which is based on prevention and early intervention. What services are provided?

Work Health Assessment screening of new employees

Health surveillance where required to protect employees against work related illness

Immunisations and blood tests to protect both staff and patients

Advice on rehabilitation back to the work environment Advice to employees and managers regarding an individual’s fitness for work

Advice on the management of sickness absence

Advice on work related health issues

Risk assessment and follow up after an inoculation/splash incident

Outbreak monitoring and advice

Stop smoking advice

Physiotherapy/back care assessment and treatment Counselling for staff experiencing distress due to problems at home or work

Manual handling training and advice. Advice regarding ill-health retirement.

The Occupational Health Team

The dedicated occupational health team consists of:

Occupational Health Service manager

Occupational Health Physicians Specialist Occupational Health nurses

Screening nurses

Administrators

Senior physiotherapists and manual handling trainers

Counsellors When should you attend the occupational health department?

If you have been given an appointment to attend for Work Health Assessment/health surveillance/ sickness absence or pregnancy risk assessment review

For vaccination update/ subsequent vaccinations or blood tests as requested by the occupational health department

Following a needlestick or inoculation incident (out of hours you must attend A&E immediately and inform Occupational health on the next available working day)

If you have an undiagnosed skin rash



For assessment of your skin if you suffer from dry/sore hands at work If you have vomiting &/or diarrhoea please telephone to inform the occupational health

dept. and receive advice

If you have work related ill health

Self-referral to Physiotherapy is indicated for musculoskeletal problems i.e. low back pain.

Occupational nurse advisors are available to give telephone advice if you are unsure whether you need to attend the department

Please note that we are not a G.P service. Please ensure that you are registered with a G.P for advice on all other minor illnesses and injuries. Alternatively you should ring NHS Direct on: 0845 4647 or attend a local walk in centre such as the North Ormesby Health Village Resolution Centre’s Urgent Care Centre located in North Ormesby, Middlesbrough. Confidentiality Medical and personal information held and known by the Occupational Health service and its staff is regarded as strictly confidential. It will not be shared with your manager or human resources without your informed consent being obtained first. An exception to this rule would only arise if the Occupational Health Professional believed that keeping the information confidential would pose a risk to yourself or others. Any intention to disclose such information would always be discussed with you at the time. How to locate the Occupational Health Department

There are occupational health departments on both James Cook University Hospital and Friarage hospital sites: South Lodge is located on the JCUH site as a separate building close to the helicopter pad. Hours of opening are Monday to Thursday 8.30 - 5pm, Friday 8.30 - 4.30. The Friarage occupational health department is located in the corner of the car park adjacent to the postgraduate centre. Hours of opening are: Tuesdays 9.00 – 4.30 and Thursdays 9.00 – 4.30. Please note that both departments close daily between 12.30 – 1.30pm. All calls for enquiries, referrals and appointments are received by James Cook staff between Monday and Friday. There is also a clinic at Redcar Primary Care Hospital scheduled on the 1st Tuesday of the month. Appointments can be arranged through the department at JCUH for this clinic The Counselling team are situated at Park View Medical Centre, 276 Marton Road, Middlesbrough and at the Friarage Occupational health Department Contact details

Both occupational health departments operate an appointment only system, with exceptions for needle stick injuries / sharps injuries and hand / skin problems, which will be seen as priority at the time of occurring. All appointments for occupational health clinics, including physiotherapy and counselling can be arranged by contacting 01642 282482 or ext. 52482 Updated November 2013



Occupational Health Welcome Letter Welcome to South Tees NHS Foundation Trust. We do hope you enjoy your time working in the Trust. I am writing to introduce the Occupational Health Department, which is based in the South Lodge of the James Cook University Hospital and the Friarage Hospital, South Tees NHS Foundation Trust. All of us at South Tees NHS Foundation Trust take the health and wellbeing of our staff very seriously. We want to help to improve your health so that you stay fitter for longer. Healthy staff produce better patient care as well as having a more fulfilling work life balance. As you commence your new role with us, if there are any aspects of your health that you are concerned about in relation to your work, please feel free to contact the Department to discuss this further with us. We have Occupational Health Nurse Specialists who are trained to deal with a variety of work and health related issues. James Cook University Hospital’s Occupational Health Department operates an appointment only system, which is accessible from: South Lodge, located on the James Cook site as a separate building close to the helicopter pad.

Hours of opening are Monday to Thursday 8.00 - 5pm, Friday 8.30 - 4.30. The Friarage occupational health department is located in the corner of the car park adjacent to the postgraduate centre. Hours of opening are: Tuesdays 9.00 – 4.30 and Thursdays 9.00 – 4.30. Please note that both departments close daily between 12.30 – 1.30pm For all healthcare workers/clinical workers (e.g. Doctors, Nursing Staff, Healthcare Staff) it is important you are offered appropriate immunisations against infections which you may be exposed to during your role and it is your professional responsibility to maintain an up to date

vaccination status to protect yourself and patients. The precise range of immunisations offered will depend on your area of work. However, if you have had previous immunisation with an additional NHS Trust/GP or healthcare organisation, we would welcome this information being supplied to our Department. Immunisation details of particular importance are:

Hepatitis B Vaccination

Rubella, Measles and Varicella (chicken pox) Vaccination

TB Status We do hope to see you in the Department over the forthcoming months as we take a proactive approach to safeguarding your health and improving your wellbeing. Our contact number is 01642 282482 (Ext.53204).

Yours sincerely

Pam McCourt

Occupational Health Manager Occupational Health Department



MINISTRY OF DEFENCE HOSPITAL UNIT (MDHU) AT THE FRIARAGE

Following the decision taken by the Ministry of Defence to close the Duchess of Kent Hospital, Catterick Garrison, the former Northallerton Trust entered into a partnership with the MOD to provide medical care to military personnel. The Ministry of Defence Hospital Unit (MDHU) was based at the Friarage Hospital from 1 July 1999. Military doctors, nurses and scientists were fully integrated into the hospital services. Medically trained personnel from all three services serve in MDHUs. The MDHU at the Friarage Hospital is mainly staffed by the Army, but occasionally personnel from other services work there. Most military staff work at the Friarage Hospital, though some also work in A&E, ITU, AAU and Operating Theatres at The James Cook University Hospital and in Outpatients at Duchess of Kent Hospital in Catterick Garrison. The aim is to develop a unit, which ensures military personnel are trained for their operational role through training, education and direct patient care. It also promotes an environment that enhances military ethos so that military personnel have the appropriate skills when they are called away on active service. The MDHU’s primary role is to provide Medical support to the Armed Forces in theatre of operations; and Environmental health and infection control education.

Military personnel must take part in a variety of training programmes, both professional and military. The professional qualifications are the same as civilian colleagues, must comply with the standards set by professional bodies and have the same requisite for Continual Professional Development and accountability. They also have to complete Unit, Career, Military and Operational training as required. These all have an impact on professional advancement and progression through the ranks of the service.

For each military patient seen or treated in the MDHU, the MOD pays the Trust an agreed fee. The Trust pays an agreed fee to the MOD for each of the Military members of staff that is employed in the MDHU. Contact details:

09:00 – 16:30 Mon – Fri 01609 763100 All other times 01609 779911 Ask for MDHU Duty Officer



STAFF SIDE UNIONS

JOINT PARTNERSHIP COMMITTEE

Joint Partnership Committee meets on a monthly basis. PAY AND CONDITIONS OF SERVICE

Since 1 January 1994, South Tees has implemented its own pay and conditions of service that differ from Whitley Council pay and conditions. A core committee of representatives and full-time officers of the recognised unions negotiate locally on behalf of Trust contract employees. HEALTH AND SAFETY COMMITTEE

Trade Union representatives also form part of a joint health and safety committee. They represent their members on all issues that relate to health and safety. RECOGNITION OF TRADE UNIONS

South Tees Hospitals NHS Foundation Trust recognise, for collective bargaining purposes, any trade union that has 30 members or more. What this means in simple terms is that any such trade union is able to negotiate, on behalf of their members, on all aspects of pay and conditions. It also means that the unions should be consulted, on many aspects of the work environment, by the management side. IF YOU ARE NOT MEMBER OF A UNION

The Staff Side unions, as well as representing their members’ views, also represent them on disciplinary and grievance issues and negotiate their pay and conditions of service. The individual trade unions also offer their members many other services, including legal and financial ones. If you wish to receive any further information on the services offered by the unions within South Tees, contact one of the representatives listed overleaf. A list of staff union representatives is feature on the ‘Who’s Who’ on the intranet site

http://stis-001/structure/whos_who_june_2013.pdf



WELCOME TO THE DEPARTMENT OF CHAPLAINCY AND SPIRITUAL CARE

South Tees Hospitals NHS Foundation Trust employs staff not only to help with physical needs, but also to help support patients, relatives, carers and staff with their spiritual needs. The Chaplaincy Team is available to help meet these spiritual needs no matter what a person's faith or belief system may be. The team can also contact religious leaders of other faiths if that is requested. The Chaplains are a resource for the Trust. They seek to foster spirituality and community within the Trust. To be a resource for listening, literature (including Bereavement and Cultural booklets), training and staff support.

Please feel free to call a Chaplain. The team, which includes chaplains and chaplaincy volunteers, visit the wards regularly and welcome requests for visits.

Chaplains are available for staff. They can be contacted at any time to listen, talk, advise or counsel. All such meetings are confidential.

Chapel at the James Cook University Hospital

The Chapel of the Good Samaritan, near the North Entrance, is open and lit during the day and the night for you, your family and your friends to visit. It's a special place of peace and quiet, of prayer, stillness and reassurance. It is hoped that people of many faiths and none, will find it a tranquil and safe haven. Details about services held at the chapels are on notice boards daily outside the entrance to the chapels.

Other Faiths

There is a Masjid, a Muslim Prayer Room and wash facility, adjacent to the Chapel. The Chapel is available for prayer or quiet reflection should you wish. There are Quiet Rooms and Quiet Gardens that are available.

Chapel at the Friarage Hospital. The Chapel near the Main Entrance on the ground floor is available for you. You are welcome to enjoy the peace at any time. It contains literature you may find helpful. Other faiths are welcome to use the Chapel. Community

The community sites do not have Chapels but feel free to contact the Chaplains who will deal with matters or direct you to local ministers as appropriate.

THE CHAPLAINCY TEAM

Church of England Malcolm Masterman JCUH Margery Grange JCUH

Marie Edwards JCUH Roman Catholic Len Collings JCUH

James Blenkinsopp Friarage Hospital Free Church Sarah Ramsden JCUH

Rodney Breckon Friarage Hospital & JCUH Robert Gee Friarage Hospital Elisabeth Jordan Friarage Hospital

Contact the Chaplains JCUH on ex 54802 or bleep via switchboard Friarage on ex 63275 or through switchboard



LIBRARY SERVICE

The service, based at The James Cook University Hospital (Middlesbrough), and at the Friarage Hospital (Northallerton), aims to support the work and training of all staff employed by South Tees Hospitals NHS Foundation Trust and all medical, nursing and allied health students on work placement. Overview of Services

Enquiry service (in person, by telephone, email)

Borrow books

Information skills training

Interlibrary loans

Literature searching Photocopying

Study/computer facilities James Cook - please contact the Rodney Cove-Smith Library ext. 54820 or email:

[email protected]

Opening times:

Mon – Thu 8.30am-6pm Fri 8.30am-5pm

Friarage - please contact the library x62525 or email [email protected]

Opening times

Mon – Fri 9am-5pm Access to the library outside of these hours is available by means of a security ‘swipe card’ which can be obtained from the Friarage library.

For more information about library services and links to relevant websites, please view the Library Services page on the Intranet/Internet.






RESUSCITATION DEPARTMENT (ACADEMIC DIVISION)

Our aim is to ensure robust clinical systems throughout the Trust and to deliver resuscitation

training in a standardised and organised way to maximise the chances of survival of patients

suffering from a cardiopulmonary arrest. The role can be summarised as having four aspects:

Clinical

Professional resource

Clinical advice on all aspects of resuscitation in both adults and paediatrics

Maintaining clinical credibility by attending and monitoring cardiac arrest situations

Training

To plan, organise and disseminate training in basic and advanced techniques of resuscitation

Professional advice and support in relation to education and training

To co-ordinate and teach on nationally recognised life support courses

Managerial

To identify and monitor the service provided

Facilitate change as the service demands

To provide and monitor local policies within the Trust with regards to resuscitation

To provide advice in regard to clinical and training equipment used within the Trust

Research

To seek out and disseminate relevant research findings and to implement those recommendations

To maintain an ongoing audit within the Trust in relation to cardiac arrest situations

To participate in and/or initiate local or national research projects

As a registered centre we also provide the following courses:

Immediate Life Support / Advanced Life Support / Paediatric Life Support / Paediatric Immediate Life Support / Advanced Paediatric Life Support / Newborn Life Support / Paediatric and Neonatal Safe Transfer and Retrieval / Generic Instructors Course / Advanced Trauma Life Support / Ill Medical Patients Acute Care and Treatment

The Cardiac Arrest number in the Trust is 2222.

You should state Cardiac Arrest, Child/ (less than 16yrs) or Adult and the location of the patient. All clinical staff should undertake/ attend an annual basic life support session. This is mandatory

training. Further information can be found on the Trust Intranet at the following link:- http://stis-001/default.asp?site=academic (click on Resuscitation Link and Training Directory).

http://stis-001/default.asp?site=academic



The James Cook University Hospital – Extension number Ext 52864

Friarage Hospital - Extension number Ext 64513

Mrs D Campbell,

(Resuscitation Department Manager)

Mrs J Langthorne

(Resuscitation Officer)

Ms N Rennison, (Resuscitation Officer)

Mr D Jobling, (Resuscitation Officer)

Mrs Sarah Goodyear (Resuscitation

Department Secretary)

Mrs J Langthorne, (Resuscitation Officer)

Mrs A Atkinson, (Paediatric Resuscitation

Officer)

Ms M Yates, (Resuscitation Department

Administrator)

We have a Trust joined the National Cardiac Arrest Audit. The National Cardiac Arrest Audit (NCAA) is the national clinical audit of in-hospital cardiac arrests with the aim of improving resuscitation care and patient outcomes for the UK and Ireland. NCAA is a joint initiative between the Resuscitation Council (UK) and ICNARC (Intensive Care National Audit & Research Centre). What is NCAA? The National Cardiac Arrest Audit (NCAA) is an on-going, national, comparative outcome audit of in-hospital cardiac arrests. It is a joint initiative between Resuscitation Council (UK) and ICNARC (Intensive Care National Audit & Research Centre) and is open to all acute hospitals in the UK and Ireland. NCAA has a Steering Group - the conflict of interest document can be downloaded by clicking on the link to the right of this page. What is the purpose of NCAA?

NCAA monitors and reports on the incidence of and outcome from, in-hospital cardiac

arrests in order to inform practice and policy. It aims to identify and foster improvements in the prevention, care delivery and outcomes from cardiac arrest.

Current focus

The NCAA Team is currently focussing on data validation, the dissemination of NCAA Activity Reports and the provision of stratified/comparative data.

This data must be captured by the completion of the Trusts Cardiac Arrest Treatment form. Therefore if involved in a cardiac arrest please think Audit!

Further information can be found at:-

https://www.icnarc.org/CMS/DisplayContent.aspx?root=RESEARCH&ID=b6fbea09-61db-df11-8854-002264a1a658

Updated December 2013





USEFUL TELEPHONE NUMBERS

For further information regarding telephone extensions please see intranet site – Site index/Phone book for further telephone numbers and extension numbers together with information on short dial codes.

NAME TELEPHONE

Legal Department 01642 854716

Risk Management 01642 854699 Patient Relations department – JCUH PALS – Freephone number

01642 854500 0800 0282451

There is an answer phone available on both sites, and staff can contact the PALS Team by bleep via switchboard if necessary.

Infection Prevention and Control Team - JCUH 01642 854800 Infection Control Team - FHN 62033

Pensions - JCUH Paymasters - JCUH

Ext 53045 at JCUH Ext 53037 at JCUH

Fire Safety Advisor - JCUH

01642 854914

Health & Safety Office (in hours)

01642 854669

Health and Safety (out of hours) Advisors on call via switchboard

Security Rapid Response Faults/ Repairs to equipment e.g. utilities, environment Medical Engineering

Ext 2323

Ext 53111

Ext 54655 Chris Spence Local Security Management Specialist/Health and Safety Lead Health & Safety - JCUH

01642 854669

Information Governance – JCUH Ext 55732 Recruitment Human Resources - JCUH

01642 854610

Human Resources General Enquiries - JCUH Human Resources - FHN

01642 854811 or Ext 54811/ 01642 854803 or Ext 54803 / 01642 854346 or Ext 54346/

01642 835624 or 5624

Ext 62006 The James Cook University Hospital Marton Road Middlesbrough TS4 3BW

Main Switchboard 01642 850850

Friarage Hospital North Yorkshire DL6 1JG


Carter Bequest Primary Care Hospital Cambridge Road Middlesbrough TS5 5HN


East Cleveland Primary Care Hospital Alford Road Brotton TS12 2FF


Guisborough Primary Care Hospital Northgate Guisborough TS14 6HZ


Lambert Memorial Community Hospital Lambert Memorial Hospital Chapel Street Thirsk YO7 1LG




FOR ID BADGE

ID Badge application form

Form should be completed as appropriate and taken to the Environmental Desk, Main Mall, The James Cook University Hospital.



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