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STAFF BRIEFING. An overview of essential processes and policies. This document contains An overview of the key points within essential processes and policies Useful contacts for each area Signposts to additional policy information on the intranet. Question 1 : Are we safe?.

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An overview of essential processes and policies

  • This document contains

    • An overview of the key points within essential processes and policies

    • Useful contacts for each area

    • Signposts to additional policy information on the intranet

Question 1 are we safe
Question 1 : Are we safe?

Mental Capacity Act

Independent Mental Capacity Advocates

Safeguarding Adults

Safeguarding Children

Infection Control


Medicine Safety

Monitoring Drug Fridge Temperatures

Health and Safety

Waste Management

Medical Equipment

Safe Staffing

Mental Capacity Act


  • The Mental Capacity Act applies to everyone who works with people who lack capacity

  • Provides a statutory framework to empower & protect people who may lack capacity to make some decisions for themselves (e.g. dementia, learning disabilities, mental health, stroke/head injuries)

  • Enables them as far as possible to make appropriate decisions on their own behalf

  • Protects the rights of those who make decisions on their behalf (health workers and care workers)

  • It’s purpose is to provide clarity and safeguards around the research in relation to those who lack capacity

Mental Capacity Act

Five core principles

  • All decisions about mental capacity should be guided by five core principles:

    • Assume a person has capacity unless otherwise indicated

    • All practicable steps must be taken to help person make a decision

    • A person is not to be treated as unable to make a decision merely because it is an unwise decision

    • Any act/decision taken on behalf of someone must be in their best interest

    • Always consider the least restrictive option/intervention.

Mental Capacity Act

The Act clarifies…

  • What “lack of capacity” is:

    • A person lacks capacity in relation to a matter if at the material time he/she is unable to make a decision for himself in relation to the matter because of an impairment of the mind

    • The impairment may be temporary or permanent

  • How to assess capacity:

    • Assume a person has capacity unless otherwise indicated i.e. start from a presumption of capacity then take into account the person’s behaviour, their circumstances and any concerns raised by others

    • Assessment of capacity should be specific to the decision to be made at a particular time

    • Avoid assumptions by reference to age or appearance, or aspects of behaviour which could lead to unjustified assumptions

    • Staff always document and keep records of any assessment.

Mental Capacity Act

  • Assessment of a person’s capacity must consider the following factors:

    • Can they understand the information

    • Are they able to retain the information

    • Are they able to use or weigh that information as part of the decision making process

    • Can they then communicate their decision

  • Who assesses capacity?

    • The person delivering the care or treatment is responsible for assessing capacity in relation to the care or treatment proposed - this includes healthcare staff, social care staff, family, unpaid carers.

Mental Capacity Act

Best interests

  • Where a patient has been assessed as lacking capacity to make a particular decision, the decision-maker has to act in the patient’s “best interests”

  • The Act does not define “best interests” but provides a checklist – detailed on the next slide

  • There is a duty under the Act to consult with the carer, interested party, persons holding powers of attorney, etc. before a best interest decision is made

Mental Capacity Act

Best interests checklist

  • Avoid assumptions about the patient’s best interests merely on the basis of age, appearance, condition or behaviour

  • Consider a patient’s own wishes, feelings, beliefs & values and written statements made when they had capacity

  • Take account of views of family and carers or Independent Mental Capacity Caldicott (See IMCA slides)

  • Can the decision be put off until the patient regains capacity?

  • Demonstrate that you have carefully assessed any conflicting evidence or views

  • Provide clear, objective reasons as to why you are acting in the patient’s best interests

  • Take the less restrictive alternative or intervention.

    For more information contact safeguarding lead David Flood on ext 1624 (Bleep: 8031)

Independent mental capacity advocates (IMCA)

  • There is a legal duty for an Independent mental capacity advocates (IMCA) to be instructed where:

    • There is a decision to be made regarding SMT or accommodation

    • The person has been deemed not to have capacity to make that decision

    • The person has no close family or friends who are appropriate or practical to consult

  • Urgent decisions (“life or limb”) should not be delayed.

  • The IMCA does not:

    • Assess capacity

    • Make the best interest decision

    • Mediate between family and professionals

Independent mental capacity advocates

Free service – St George’s uses Voiceability - Hotline - 0845 0175 198

What do IMCAs do?

  • Represent and support the person in relation to their “best interests”

  • Find out the views, feelings and beliefs of the person.

  • Make sure that the person can participate in the decision-making process

  • Obtain & evaluate information

  • Look at other courses of action

  • Consider seeking a further medical opinion if necessary

  • Check the Mental Capacity Act principles and best interests process are being followed

  • Prepare a report, which the decision-maker has a legal duty to consider.

Safeguarding Adults

Everyone’s responsibility

  • All staff should:

  • Be able to recognise abuse and neglect

  • Know what action to take if they have a concern about an adult

  • Know where and from whom to access support and advice

  • Know how to access the safeguarding adults site on the intranet (documentation, information, training)

  • Be confident about information sharing

  • Understand that they have a duty to report concerns.

Safeguarding Adults

It’s your responsibility

What to do if you have a concern? – Five Rs

  • Recognise signs or symptoms of abuse or neglect

  • Respond - Listen and reassure - Think safety first

  • Report – Datix and inform your line manager

  • Record and document evidence

  • Refer to safeguarding lead/social services

    Please do not ignore the situation.

    Safeguarding adult lead is David Flood - ext 1624 (Bleep: 8031)

Safeguarding Adults

Signs / symptoms

  • Unexplained injuries – bruises, fractures or burns

  • Think history – Any inconsistencies? Unusual sites?

  • Behaviour – passive, stressed/agitated, check with family/carers (if appropriate)

  • Neglect – malnutrition, pressure ulcers, isolation, home environment, hygiene, access to services

  • Financial – basic needs not being met, unpaid bills

Safeguarding Children

Everyone’s responsibility

  • All staff should:

  • Be able to recognise abuse and neglect

  • Know what action to take if they have a concern about a child or young person (under 18 years)

  • Know what action to take if they have concerns about an adult who is a parent or carer

  • Know where and from whom to access support and advice

  • Know how to access the safeguarding children section on the intranet (documentation, information, training)

  • Be confident about information sharing

  • Understand that they have a duty to report concerns.

Safeguarding Children

Recognition of abuse and neglect

  • Physical abuse

  • Bruises, burns, fractures, - does the injury fit the history and the child’s developmental stage?

  • Neglect

  • The persistent concerns...

  • Unkempt, dirty, hungry, inappropriate clothing, DNA’s, untreated medical conditions, poor school attendance, developmental delay...

  • Emotional abuse

  • Withdrawn, behavioural issues, low self esteem, soiling, wetting, parents who are negative/critical

  • Includes impact of domestic abuse

  • Sexual abuse

  • Sexualised behaviour, language, soiling, wetting, physical signs

  • Sexual exploitation.

Safeguarding children

Be aware

  • People who can help:

  • Dr Sarah Thurlbeck x3648 (named Dr)

  • Geraldine Fraher x 5237(named nurse acute paediatrics)

  • Caroline Beazley (named nurse)

  • Marion Louki x0700 (named midwife)

  • The adult issues that may present concerns for children in their care and what to do

  • Domestic violence, drugs and alcohol, mental health issues, chronic health issues, learning disability, criminal behaviour all increase the risk to children

  • The level of training you require, depends on how often you are in contact with children

  • Have access to key documents – available via the intranet under procedural documents

  • How to contact social services

  • A critical policy for paediatric staff to understand

  • `

Infection Prevention and Control

Single-use items

  • Single-use items should be used once and discarded. Do not re-use single items

  • Discard all other unused items in a pack e.g. mouth care packs and NG syringes

  • Look for this symbol on packaging for single-use items


Infection Prevention and Control

Re-usable items

  • Re-usable items must be adequately reprocessed between each patient

    There are three levels of decontamination

  • Cleaning

    • physical removal (blood, faeces, etc) and many micro-organisms with detergent

    • mattresses, bedside lockers

  • Disinfection

    • reduces the number of micro-organisms to a safe level, spores are not usually destroyed

    • endoscopes, bedpans, commodes, crockery

  • Sterilisation

    • removes or destroys all micro-organisms, including spores

    • surgical instruments

Infection Prevention and Control

Further inspection

  • The Infection Control Manual and infection control pages are available on the intranet

  • The Infection Control Nurses are available

    • Monday to Friday 08:30 to 17:30 via Bleep 6798

    • Office 08:30 - 16:30: ext. 2459  

  • For urgent calls out of these hours please contact the on-call microbiologist via the switchboard

  • Each ward has in infection control notice board – is your board up to date?

Infection Prevention and Control

Keeping clean and clutter free

  • Ensure the Know your Responsibilities – posters are displayed on the wards to inform all who does what for cleaning- including how often areas are cleaned.

  • Ensure you know to contact the helpdesk and how to report cleaning and estates concerns and how to escalate.

  • Ext 4444 (4438/7 out of hours) for Estates and Cleaning in Atkinson Morley Wing

  • Ext 4000 (bleep 7888 out of hours) for all patient’s meals across all areas and ext 4000 for all cleaning across the rest of the Trust (SGH) (bleep 7888 out of hours)

  • Ext 1234 Trust estates team (all non AMW areas at SGH) bleep 6407 emergency engineer bleep out of hours.

  • Do you know who your cleaning supervisor is / the names of your cleaning team on the area? If not find out

  • Ensure you have your latest cleaning audits up on the Infection Control notice board. Did your staff accompany the audit team and sign off the audit ?

  • Remember to check the bed area once a deep clean has been completed to ensure that this is satisfactory before the next admission and that this has been noted.

InfectionPrevention and Control

Caring for the environment top tips

Current standards 2007 National Standards – 49 elements and 2009 NHS Cleaning Manual

Specific Risk Categories depending on levels of infection e.g. Wards - High risk

The higher the risk the more frequent the cleaning and the more frequent the auditing

Nursing /cleaning staff areas of responsibility

Duties outlined in SLA/posters in ward areas

Infectious cleans guidance on intranet

Cleaning of Body Fluids

See Infection Control policies

Use neat Milton or Haztabs


NHS Standards and responsibilities

Caring for the Environment - Top Tips and 2009 NHS Cleaning Manual

  • Have your staff had waste management training ? Ensure that all staff understand the different types of waste and ensure that this is being carried out correctly.

  • Remember to look up as well as down when reviewing your environment.

  • Ensure staff have been trained on how to clean equipment – drip stands, commodes, BP machines, resus trolleys, raised seats, clinical storage racks, pc’s keyboards and screens, mattresses, body fluids.

  • Linen – ensure that this area is separate from other items and that it is clean and tidy – always reject linen if not up to standard.

  • Are all gel/soap dispensers/toilet paper/hand towels/aprons full all the time ?

  • Curtains are changed every 6 months in addition to the changing of these after patients have left the Trust. These records are kept with the cleaning teams.

  • Further support can be given by contacting the Facilities teams via ext 1234 or on bleeps 7159 / 7664 or on ext 0058.

National colour coding scheme for hospital cleaning materials and equipment

  • All NHS organisations should adopt the colour code (right) for cleaning materials.

  • All cleaning items, for example, cloths, (reusable and disposable) mops, buckets, aprons and gloves should be colour coded.

Medicine Safety materials and equipment

  • Ensure you have read and understood the relevant sections of the medicines policy and know how to access it

  • Never administer anything you are not confident about or assessed as competent to do. If not sure speak to your named pharmacist

  • Never give any medicine (or undertake any procedure) without confirming the patient’s identity

  • Ensure all medicines are always locked away and not left on lockers or in the open

  • Ensure all cupboards, fridges, PODs and trolleys are locked and the keys are with a registered nurse or midwife

  • Do not administer and leave medicines with patients to take later, this must be observed (may be different for some in offender healthcare)

  • Ensure that if any medicines are omitted this is documented clearly with reasons

  • Ensure you attend all regular updates and relevant training

  • Please ensure you report and record all near misses or errors on Datix and tell your manager

  • Make sure allergies are clearly documented on prescription charts

Monitoring Drug and Fridge Temperatures materials and equipment

Previous CQC inspection highlighted drug and fridge temperatures as a risk

  • CQC said - “Patients were not protected against the risks associated with medicines because the temperatures of medicines storage areas on some wards were not monitored consistently.”

  • Key points

    • Ensure all drug fridges must have a calibrated thermometer to monitor minimum and maximum temperatures

    • Clinical areas must use the trust approved temperature monitoring log form

    • Drug fridges must be monitored on a daily basis

    • Any deviation in drug fridge temperature must be acted upon, following the temperature deviation procedure

  • Since August 2013, a Trust-wide Drug Fridge Thermometer Calibration Service has been rolled out

    • Calibrated thermometers have been purchased and installed in clinical areas for monitoring of minimum and maximum temperatures

    • Policies are available on the intranet, Pharmacy Department page, for drug fridge temperature monitoring, temperature deviation and for defrosting drug fridges. See link:


    • Key clinical staff have been trained on the fridge thermometer calibration process and monitoring requirements.

      For further training please contact [email protected] or [email protected]

Health and Safety materials and equipment

Managing health and safety and risk assessments

A Risk Assessment – The process of identifying risks to and from an activity and assessing the potential impact of each risk (CQC Guidance Essential standards of Quality and Safety 2009)

  • The Management of Health and Safety at Work Regulations (1999) state:

    • Every employer shall make a suitable and sufficient assessment of the risks to the health and safety of employees to which they are exposed to at work (staff, volunteers)

    • The risks to the health and safety of people not in their employment (Patients, Visitors etc)

  • Only trained and competent people should carry out a risk assessment, for training or guidance please refer to the Risk management policy or contact:

    • The risk management department ext 4054 or 4966 or The Health and Safety department ext 3309 or 4043

  • Examples of patient specific risk assessments: VTE, SBAR, EWS, pressure ulcers and falls

  • Examples of non-patient specific risk assessments: manual handling, fire, emergency evacuation, environmental.

Health and Safety materials and equipment

How to carry out a risk assessment

  • Identify the hazards - consider human, environmental and emergency factors

  • Consider who may be harmed and how - consider patients, staff, visitors and anyone else who may be in the area. Also consider personal factors like age, medication, medical conditions

  • Evaluate the risks and decide on risk control measures - Use the relevant risk scoring matrix to score the risk and decide on the control measures required to reduce the risk to an acceptable level

  • Record the findings - To demonstrate that the assessment has been carried out and to instruct other members of staff on the required control measures

  • Review and update - risk assessments must be reviewed at time intervals relevant to the assessment. If anything changes in regards to the patient, the control measures required or the environment, then this must be recorded in the risk assessment.

Waste Management materials and equipment

Correct waste segregation

Infectious clinical waste

Domestic waste

Clinical waste for incineration


Sharps bins in caddies

with lids of same colour

Waste Management materials and equipment

Correct waste segregation

Pedal bins

The pedal bins used in clinical areas should be

rust-free and clean. Silent-closing, rigid body bins

can be obtained from EHP via Agresso. For 70 litre

rigid body bins the product code is HSBM1030SC,

when ordering please state colour required. For the

disposal of old bins please contact Waste Manager.

For further advice contact the

Waste Manager on x3169

Clinical Waste

Domestic Waste

Sharps bins

Sharps bins should:

1. Have the lid firmly attached

2. Not be filled above the line

3. Not to be used when ¾ full

4. Have the label completed to show where and when used

5. Contain only sharp objects, which should be placed into a sharps bin as soon as they have been used

6. Always be mounted on a bracket, available from Waste Manager, or in POUD tray.

Medical Equipment materials and equipment

  • Medical Equipment must be:

    • Safe: Properly maintained and used correctly

    • Suitable for its purpose

    • Available

  • Support is from Medical Physics and Clinical Engineering Department Practice Nurse Educators and the Procurement Department

  • Policies

    • Medical Devices Management and Use policy

    • Medical Devices Training Policy

    • Procurement policy

Medical Equipment materials and equipment

  • Only use equipment you are competent to use. Request training as required

  • Only use equipment that you are sure is fit for the purpose (that is, the correct equipment and accessories to perform the task)

  • Ensure any equipment checks required are carried out

  • Report any faults or concerns about equipment function to Medical Physics, and take equipment out of use

  • Report any safety incident involving equipment, and take the equipment out of use (& save all consumables for investigation).

Medical Equipment materials and equipment

  • Only use ‘Know how’ to borrow from the equipment library

  • Return equipment to the equipment library when finished with – someone else will need it

  • ‘Know how’ to request pressure relieving mattresses including out of hours.

  • Assess and return pressure relieving mattresses not required – someone else needs one

  • Assess whether any lack of equipment is detrimental to patient outcomes. Make senior staff aware of any lack. Budget holders to manage locally bought equipment, and to present capital equipment requests to their division

Safe staffing materials and equipment

  • The Trust has a duty to ensure staffing levels are sufficient to maintain safety, minimise risks to patients and provide quality care. Nurse staffing levels make a difference to patient outcomes, patient experience, quality of care and the efficiency of care delivery (all staff should read the safe staffing policy).

  • We should work towards having the right staff with the right skills in the right place at the right time with the right leadership.

    Safe staffing can be defined as whether staff can safely:

  • Complete vital signs observations - (especially post-operatively, and 1:1 ‘specials’)

  • Assist patients with nutrition

  • Assist patients with hydration (drinks and intravenous or nasogastric fluids)

  • Care for pressure areas

  • Administer drugs and and oxygen therapy

  • Take their statutory rest breaks

  • Complete risk assessments for new patients including PUP and MUST.

Safe Staffing – top 10 tips materials and equipment

  • Each unit, ward, department and community service will have an agreed number of Nurses, Midwives and Health Care Assistants for each shift of the 24-hour day – ensure you know what these numbers are.

  • The duty roster should be planned in advance with the aim to provide the best possible nursing skill mix

  • Safe staffing relies on good management of your rota. Ensure that all permanent staff hours are used. Ensure everyone on short or long term sickness is managed with the aim of getting them back to work as quickly as possible

  • Gaps in the nursing numbers due to vacancy or sickness may be covered by bank staff or agency staff (refer to your locally agreed procedure for authorisation)

  • Assess your patient acuity/dependency at handover and ensure you have sufficient staff to cover the required work for the shift. Review your skill mix and ensure staff are allocated appropriately to cover the nursing workload

  • If you have a concern, talk to your Matron / Head of Nursing. If they are unable to assist, ensure your Divisional Director of Nursing (DDNG) is contacted. They are expected to liaise with other senior staff in the organisation to provide a solution

  • Be clear about what you can and cannot do. Have precise information on staff numbers, skill mix, patient dependency and the definition of safe staffing (above) to support your case for more staff or other interventions (eg. Stopping admissions or transfers for two hours). Be clear about what you could stop and for how long (eg. Escorts).

  • Once your concerns have been highlighted and acted upon, record your staffing situation before 10am using the real time RaTE system.

  • Remember that any change to staffing or dependency can affect staffing for the following 24 hour period. Ensure a plan is in place to respond to this.