New Employee Induction Flowchart - PDF

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					                                                            Policy No:     PP30

                                                            Version:       6.1




         Name of Policy:             Induction Policy and Procedure




         Effective From:             29/01/2010




          Date Ratified      01/09/2008
          Ratified           Human Resources Committee
          Review Date        01/10/2010
          Sponsor            Director of Health Development and Modernisation
          Expiry Date        29/01/2013
          Withdrawn Date



This policy supersedes all previous issues.
                               Version Control

Version Release   Author /      Ratified By /      Date            Changes
                  Reviewer      Authorised                    (Please identify page
                                     By                                no.)
  1.0    April                  Trust Board      Mar 2001
         2000
                                    JCC          17/01/2001

                                    TPF          14/06/2000

  2.0    Sept                    Trust Board     22/09/2004
         2004
                                 Gateshead       08/09/2004
                                 PCT Trust
                                   Board

                                    TPF          08/09/2004

                                    JCC          21/07/2004

  3.0     Jan     J Bourke       Trust Board     25/01/2006
         2006
                                    JCC          19/10/2005

                                    TPF          14/12/2005

  4.0     Oct     J Bourke       Trust Board     Oct 2006
         2006
                                    JCC          27/09/2006

                                    TPF          11/10/2006

  5.0    Sept     J Donnelly        JCC          17/09/2008
         2008
                                  JCC Sub        Aug 2008

                                    HRC          01/09/2008

  6.0    May      J Donnelly        JCC          17/09/2008
         2009
                                  JCC Sub        Aug 2008

                                    HRC          01/09/2008

  6.1     Jan     M Darroch         N/A             N/A          Minor wording
         2010                                                   amendments to
                                                              comply with NHSLA
                                                                 requirements



                                                                                      2
                     GATESHEAD HEALTH NHS FOUNDATION TRUST

                       PERSONNEL POLICIES AND PROCEDURES

                        PP30 INDUCTION POLICY & PROCEDURE


CONTENTS

Section
                                                                                    Page
1     Introduction                                                                    5

2     Corporate and Healthcare Professionals Induction                                5

3     Roles and responsibilities                                                      6

4     Process for ensuring completion of all aspects of the programme within          7
      specified timescales

5     Content of the induction programme                                              7

6     Process for ensuring that all new staff are booked onto corporate induction     7

7     Process for ensuring that all staff attend relevant corporate induction         8

8     System by which attendance at corporate induction is recorded and               8
      co-ordinated centrally

9     Method of evaluating the effectiveness of corporate induction                   8

10    Process for monitoring compliance with all of the above                         8

11    Local induction                                                                 9

12    Roles and responsibilities                                                      9

13    Minimum standards for the content of local induction programmes                 11

14    Process to identify and meet immediate training needs                           12

15    Process for ensuring completion of all aspects of the programme within agreed   12
      timescales

16    System for ensuring that all staff receive local induction                      12

17    System by which local induction is recorded and co-ordinated centrally          12

18    Method of evaluating the effectiveness of local induction                       13

19    Process for monitoring compliance with the Policy                               13

                                                                                          3
APPENDICES

                                                                      Page

1    Induction of Junior Doctors in Training                          14

1a   Generic induction programme for doctors in training              19

1b   Shadowing experience for F1 trainees                             21

1c   Mandatory Training programme                                     24

1d   Doctors in training local induction checklist                    25

2    Example Follow up letter                                         27

3    Corporate and Healthcare Professionals induction programme       28

4    Trust Induction Follow up flowchart                              31

4a   Example CANX 1 letter                                            32

4b   Example DNA 1 letter                                             33

4c   Example Missed Session 1 letter                                  34

4d   Local Induction Follow Up Process                                35

5    Employee/Manager checklist                                       36

6    Induction flowchart for permanent staff                          48

7    Induction process and checklist for bank staff                   49

8    Induction process for students                                   51

9    Induction checklist for volunteers                               52

10   Induction process for locum medical staff                        53

11   Induction process and checklist for agency and temporary staff   54

12   Confirmation of local induction pro forma                        56




                                                                             4
                    PP30 - INDUCTION POLICY AND PROCEDURE

1.   Introduction

     This policy is relevant to all grades of staff, including Non-Executive Directors,
     senior managers, senior medical staff, visiting professionals and students. The
     arrangements which apply to junior doctors and specialist registrars are detailed in
     Appendix 1 of this policy.

     The Trust Board, through the Director responsible for HR, is responsible for and
     committed to promoting equality and to eliminating unlawful discrimination within
     the Induction process. It is committed to ensuring that all new permanent members
     of staff, temporary staff, students, and volunteers are appropriately inducted to
     enable them to undertake their duties competently, and to protect their own well-
     being.

     Induction is a key element of the recruitment process. It helps develop a sense of
     belonging and encourages the new employee to recognise the contribution that
     they will make to the success of the organisation. Effective induction ensures that
     people are developed effectively within agreed timescales into their new role so that
     they can operate to the required standard and in as safe a manner as possible.

2.   Corporate Induction

     2.1   Permanent staff

           This is a two-day programme, which is held on a monthly basis and is
           mandatory for all staff newly recruited to the Trust.

           New members of staff need to attend corporate induction as soon as
           possible after their start date and no later than 8 weeks after commencing
           employment. Healthcare professionals are required to attend an additional 2
           mandatory induction days. Nurse bank staff must attend the 4 day corporate
           induction before they commence employment. All new members of staff
           must also attend the one day Introduction to Moving and Handling workshop,
           in addition to the Trust Induction.

           It is the policy of Gateshead Health NHS Foundation Trust to remunerate
           staff who attend corporate induction, whose working hours fall outside of the
           days scheduled. This remuneration may take the form of payment in single
           time or days in lieu.

     2.2   Temporary staff

           For temporary members of staff the use of the corporate induction
           programme for these personnel should be considered depending on the
           nature and length of the appointment. If the person is to be in post for more
           than one month they should attend the corporate induction day. However
           local induction procedures must be carried out with all of these personnel on
           commencement of their employment/placement with the Trust. Section 11
           gives details of the minimum requirements for local induction for these
           personnel.

                                                                                        5
3.   Roles and responsibilities

     3.1   Manager:

           •     Ensure that a date has been arranged for corporate induction and,
                 where appropriate, healthcare professional induction and the one day
                 Introduction to Moving and Handling workshop.

           •     Make sure that the new employee attends corporate induction. This
                 must be no later than 8 weeks after commencing employment. If the
                 original date is cancelled, a further date must be rearranged.

     3.2   New member of staff:

           •     Ensure they      attend   corporate   induction   within   8   weeks   of
                 commencing;

           •     Actively engage in induction by: completing corporate and local
                 induction; participating in a CONTACT appraisal within 1 month of
                 starting.

           •     Record their learning and development to support their application of
                 knowledge and skills to meet the KSF outline for their post.

     3.3   Organisational Development & Training (OD&T) department:

           •     Co-ordinate and administer the 4 day induction programme;
           •     Make sure that the monthly induction programmes take place;
           •     Follow up those staff who did not attend and arrange an alternative
                 date for them;
           •     Record attendance against the new starters list for that month and
                 input data on the in-house database;
           •     Provide information to managers on a monthly basis of staff who have
                 not attended corporate induction and/or not completed an appropriate
                 local induction;
           •     Collate and summarise evaluation forms and feedback to
                 facilitators/trainers;
           •     Review the content of the programme on a regular basis to ensure it
                 meets organisational requirements.

     3.4   Personnel Department:

           •     Reserve a place on the next available induction programme for new
                 employees;
           •     Inform the new employee of this date via their letter of appointment;
           •     Forward an induction programme and staff handbook to new
                 employee with their letter of appointment;
           •     Copy appointment letter with induction dates to the individual’s line
                 manager/supervisor;
           •     Inform OD&T of any cancellations prior to the induction programme
                 taking place.
                                                                                        6
     3.5   Trainers:

           •      Deliver their session on each corporate and healthcare professional
                  day;
           •      Keep their own attendance records if required;
           •      Update and review their sessions on a regular basis in light of new
                  guidance. Each presentation/session must be version controlled and
                  kept by the trainer;
           •      Keep a copy of the summarised evaluations for their portfolios;
           •      Attend induction review meetings as and when required;
           •      Find a suitable replacement to deliver the session if they are unable to
                  do so.

4.   Process for ensuring completion of all aspects of the programme within
     specified timescales

     The Trust’s OD&T Department has a responsibility to ensure that sufficient
     corporate/healthcare professional induction programmes are scheduled to meet the
     demand of incoming new starters.

     The Personnel department will ensure that new employees and their line managers
     are notified in writing of the date of the induction programme in advance of them
     commencing employment to ensure attendance within 8 weeks of their start date.

     Using the new starters list as a basis, the OD&T Department will follow up promptly:

     •     those staff who did not attend, to schedule their attendance in the following
           month;
     •     those who do not have a corporate induction date scheduled;
     •     those who have not completed local induction;

     A staged process is in place within OD&T whereby both individuals and line
     mangers are contacted requesting this information or action. Appendix 2 gives an
     example of a follow up letter.

5.   Content of the corporate induction programme(s)

     See Appendix 3 for details of the corporate and healthcare professionals induction
     programme and the Trust wide mandatory training programme.

6.   Process for ensuring that all new staff are booked onto corporate induction

     In accordance with the Trust’s Recruitment and Selection Policy and Procedure
     PP10a and PP10b, it is the responsibility of the Personnel Department to reserve a
     place on the Corporate Induction programme and, if appropriate, the healthcare
     professional programme for new employees. The Personnel Department will also
     inform the new member of staff via their letter of appointment of the date and
     venue. A copy of this letter will be forwarded to their line manager by the Personnel
     Department to ensure they are also aware of this date well in advance.




                                                                                        7
     For those staff not employed directly through Personnel, it is the responsibility of
     the appointing manager to book a place on the Corporate Induction Programme
     and to inform the new member of staff of the date.

     It is the responsibility of the line manager/supervisor to ensure their new employee
     attends the Corporate Induction Programme and, if appropriate, the healthcare
     professional induction programme.

7.   Process for ensuring that all staff attend relevant corporate induction

     It is a mandatory requirement that all employees within the scope of this policy
     comply with these terms and condition. Failure to do so may result in disciplinary
     action.

8.   System by which attendance at corporate induction is recorded and co-
     ordinated centrally

     The OD&T Department will keep an electronic record of those staff who have
     attended corporate and healthcare professional induction programmes.

     To ensure appropriate attendance records are up to date, the OD&T Department
     will run a new starters list at the beginning of each month. This list will then be
     used to record completed aspects of induction and will instigate the follow up
     process for each individual. Appendix 3 details the follow up process by way of a
     flowchart, example follow up letters are included.

     Cumulative non attendance will be tracked and reported to managers on a monthly
     basis. Members of staff who do not attend are informed that it is a mandatory
     requirement that all new employees within the scope of this policy comply with
     these terms and conditions and that failure to do so may result in disciplinary action.

9.   Method of evaluating the effectiveness of corporate induction

     The content of the Trust’s corporate induction is reviewed on a regular basis by the
     OD&T Department. Each month new members of staff are asked to complete an
     evaluation form at the end of each day. These are returned to the OD&T
     Department for collation and then passed back to each trainer/facilitator for
     information and, if necessary, action. An assessment of effectiveness will be
     included within the OD and Training Year End Report submitted to the HR
     Committee.

10   Process for monitoring compliance with all of the above (See also Para 19)

     A report detailing those people who do not attend the corporate induction
     programme by department/directorate/division will be sent by the OD&T
     Department to the Director with responsibility for Human Resources and to the
     Trust Board, on a quarterly basis as part of the HR Report.

     The Trust will collect information from staff in post when attending training events in
     order to fulfil its legal obligations and in accordance with equality duties. (Race,
     Disability, Gender etc.)

     Compliance with this policy, including the process for checking that all permanent
     and relevant temporary staff attend corporate induction and for following up those
                                                                                          8
      who fail to attend, will be monitored annually by the OD&T Department and
      reported to the Director with responsibility for Human Resources and the Trust
      Board as part of the HR Report..


11    Local Induction

      Local induction is the induction or orientation programme arranged by the
      department in which the new employee will be working. Local induction is as
      important as corporate induction and the two should be seen as a comprehensive
      package for all new employees, regardless of whether they are permanent or
      temporary.

      11.1   Permanent staff

             Local induction must be arranged by the appointing manager, and must be
             supported by The Manager Checklist within the local induction workbook
             shown at Appendix 5. In the case of Senior Managers and Senior Medical
             staff the responsible person for local induction is the Divisional
             Manager/Divisional Director hereafter referred to as the appointing manager.

             Appendix 6 gives details of the induction process for permanent staff.

      11.2   Temporary staff

             Local induction for temporary staff must be arranged by the appointing
             manager and must be supported by the appropriate local induction checklist.

             Local induction arrangements for temporary staff are detailed in the following
             Appendices:

             Bank staff                 Appendix 7 (process and checklist)
             Students                   Appendix 8 (process)
             Volunteers                 Appendix 9 (checklist)
             Locum Medical Staff        Appendix 10 (process)
             Temporary/agency staff     Appendix 11 (process and checklist)

12.   Roles and responsibilities

      12.1   Appointing manager:-

             Permanent staff

             •      Provide the new employee with the following information upon
                    confirmation of acceptance of job offer or on the first day of
                    employment:

                    •     Induction schedule/timetable;
                    •     Name of ‘buddy’ (notify buddy and new member of staff of
                          arrangements);
                    •     Issue and explain local induction workbook.
                    •     Department timetable to meet key personnel (if appropriate);
                    •     Departmental induction information pack (if available);

                                                                                         9
•     Ensure that the local induction manager checklist is completed within
      two weeks of appointment and filed in the employee’s personal file.
      This list should be made available for audit purposes;

•     Forward a copy of the confirmation of local induction pro forma
      (Appendix 12) to the OD&T Department within two weeks of the start
      date;

•     Ensure that the individual has completed in full a local induction
      workbook within 6 months of appointment. This should also be
      made available for audit purposes;

•     Where possible, ensure that no commitments are scheduled for the
      first week of appointment for the new member of staff. This time
      should be dedicated to induction, where the individual is welcomed
      into the department and introduced to other relevant areas;

•     Monitor the effectiveness of local induction, ensuring the quality and
      timeliness of the local induction process

•     Update employees returning to work from maternity leave; long term
      sick, unpaid leave etc on new developments and changes which have
      occurred during their absence. In particular employees should be
      made aware of any changes relating to their job role, their
      department/division and the Trust and changes or amendments to the
      Trust policies and procedures. They should also be introduced to any
      new staff with whom they are likely to come into contact;

•     Ensure that an employee transferring, or on secondment, to another
      area within the Trust is given the same departmental induction as any
      new member of staff.

Temporary staff

•     Ensure the new employee attends the corporate Induction day if their
      contract is for longer than one month or alternatively attends an
      appropriate induction day eg student nurse induction;

•     Induct the new temporary member of staff into the department,
      whether they are working for one day or for a longer period of time;

•     If the temporary member of staff is to be in post for longer than one
      month, issue and explain the local induction workbook and ensure
      completion of appropriate sections;

•     Ensure that the appropriate induction checklist is referred to,
      completed and filed within the employee’s personal file on
      commencement of work. This list should be made available for audit
      purposes;

•     Forward a copy of the confirmation of local induction pro forma
      (Appendix 12) to the OD&T department within two weeks of the
      employees start date; and

                                                                         10
             •       Identify and address any immediate training needs.

      12.2   New member of staff:

             •       Discuss with their line manager or nominated person any immediate
                     training needs and actively engage in an appropriate local induction
                     programme;

             •       If a Senior Medical member of staff, ensure that they arrange their
                     own basic Life Support training with the Resuscitation Officer;

             •       If appropriate, complete local induction workbook within 6 months of
                     starting and sign off with line manager. This workbook, should be
                     made available for audit purposes;

             •        Complete with the appointing manager, the appropriate local
                     induction checklist within 2 weeks of starting and sign to confirm
                     local induction has taken place.

      12.3   OD&T department:

             •       Referring to the new starters list, follow up with new members of staff
                     and/or their appointing managers if they have not returned the
                     confirmation of local induction sign off sheet (Appendix 12) or
                     completed a CONTACT appraisal if appropriate.

      12.4   Buddy

             •       This person will provide ongoing support and assist with the
                     individuals’ orientation, particularly during the first 3 months of
                     employment.

      12.5   Personnel department

             •       Advise Senior Medical Staff of the need to attend basic life support
                     training. It is the responsibility of the Senior Medic to make
                     arrangements by contacting the Resuscitation Officer.

13.   Minimum standards for the content of local induction programmes

      As a minimum standard the following issues must be addressed at local induction:

      •      Introduction to staff;
      •      Orientation to wards/clinical areas;
      •      Expectations of post;
      •      Limitations of post;
      •      Familiarisation with equipment and procedures, and appropriate training
             requirements;
      •      Local emergency procedures including fire and summoning help in an
             emergency;
      •      Bleep system, resuscitation procedures;
      •      Local policies and procedures;
                                                                                         11
      •      Medication common to the area and patients group directives, where
             applicable;
      •      Sources of help and advice;
      •      Mentorship.

14.   Process to identify and meet immediate training needs

      In accordance with the CONTACT Policy PP37, it is the line manager’s
      responsibility to nominate an appraiser to carry out a CONTACT appraisal meeting
      within one month of appointment for the new member of staff . The initial appraisal
      meeting will include the discussion and agreement of work objectives and a
      personal development plan (PDP) to identify immediate training needs.

      The line manager or appraiser must also discuss the NHS Knowledge and Skills
      (KSF) post outline with the new member of staff and agree development needs
      required to meet the foundation subset and (if applicable) enable the new member
      of staff to progress through the foundation gateway.

      For temporary staff it is the appointing manager or nominated person’s
      responsibility to meet with the individual and identify and address any immediate
      training needs. In the case of medical and agency staff this person is also required
      to carry out a competency assessment before that person uses any equipment.

15.   Process for ensuring completion of all aspects of the programmes within
      specified timescales

      It is the line manager’s responsibility to ensure that, as a minimum, an appropriate
      induction checklist is completed with each new member of staff within 2 weeks of
      the start date and a copy is retained on the individual’s personal file.

      The line manager must also ensure that the local induction pro forma (Appendix 12)
      is completed and returned to the OD&T department within 2 weeks of the
      individual starting.

      It is a mandatory requirement that all employees within the scope of this policy
      comply with these terms and conditions. Failure to do so may result in disciplinary
      action.

16.   System for ensuring that all staff receive local induction

      It is the line manager’s responsibility to ensure that all new members of staff receive
      an appropriate local induction. As a minimum an induction checklist (Appendix 5)
      should be completed and a copy of the completed local induction pro forma
      (Appendix 12) should be sent to the OD&T department within 2 weeks.

      For temporary staff it is the appointing manager’s or nominated person’s
      responsibility to ensure that all new members of staff receive an appropriate local
      induction. As a minimum the induction checklist (Appendix 11) should be referred
      to and completed.

17.   System by which local induction is recorded and co-ordinated centrally

      The Trust requires confirmation that a robust local induction has taken place.
      Managers must complete the pro-forma (Appendix 12) and return a copy to the
                                                                                 12
      OD&T Department for recording purposes and retain a copy on the individual’s
      personal file.

      Referring to the new starters list, the OD&T department will keep a record of all new
      members of staff and record, whether or not a completed pro forma has been
      returned and PDP has been received . The OD&T department will follow up with
      individuals and managers who have not returned this form.

18.   Method of evaluating the effectiveness of local induction

      Those people identified as responsible personnel locally for the individual local
      induction programmes should develop their own process for evaluating the
      effectiveness of local induction.

19.   Process for monitoring compliance with all of the above (see also Para 10)

      A report detailing staff (both permanent and temporary) who have not completed
      local induction per department/division will be sent to the Director with responsibility
      for Human Resources and the Trust Board as part of the HR Report on a quarterly
      basis.

      Compliance with this policy, including the process for checking that all new
      permanent and temporary staff complete local induction and for following up those
      who fail to complete local induction will be monitored by the OD&T department and
      reported to the Director with responsibility for Human Resources and the Trust
      Board on an annual basis.




                                                                                           13
                                                                               Appendix 1

                       Induction of Junior Doctors in Training


1.   Introduction

     The arrangements in this appendix are relevant to all junior doctors working and
     training within the Trust. These include doctors on formal recognised training
     rotations but also those on short term attachments and those acting in a locum
     position.

     The Trust Board, through the Postgraduate Clinical Tutor, is responsible for and
     committed to ensuring that all junior doctors in training are appropriately inducted to
     enable them to undertake their duties competently and to protect their own well-
     being.

     A common feature of junior doctors’ training is for trainees to rotate not only
     between clinical areas in the same Trust, but also between Trusts. It is imperative
     that all junior doctors who do work within the Trust are aware of their environment,
     policies and culture of the Trust within which they are working that are relevant to
     them. This is irrespective of how long they work in that Trust, and equally applies to
     junior doctors on a formal rotation and those on specific attachments.

     It should be noted that junior doctors’ training is changing, and is in transition from
     the concept of House Officer/Senior House Officer/Specialist Registrar posts to that
     of Foundation Year 1 and 2 posts and Specialty run through training posts. This
     transition period is in line with the developing Modernising Medical Careers agenda

2.   Content

     The induction process has two distinct, but closely related components. The two
     components are:

     •      Generic Induction Programme for Doctors in Training
     •      Local specialty based induction

     The Generic Induction Programme for Doctors in Training is organised through the
     Clinical Tutor’s office and is intended to give an introduction to the Trust overall.

     The local specialty based induction is designed to provide information of the
     specialty and will also include an assessment of skills competence where
     appropriate. Short term locums (1-5 days) will require a tailored local induction
     which must include those items identified below by an asterisk. For longer stays
     then a Trust and local induction is required (see below).

     The current Generic Trust Induction Programme for Doctors in Training content is
     shown in appendix 2. For F1 doctors a shadowing week programme is also offered
     (appendix 3). This is not mandatory but attendance is encouraged. F1 doctors also
     complete further Foundation Programme induction within their weekly professional
     development teaching sessions and these sessions are mandatory.


     The local specialty based induction content must include:
                                                                                         14
      Local Induction Topic                                           Short    Long
                                                                      Stay     Stay
      Orientation of local geography
      Main staff names/positions/contacts
      Leave information
      Rota/shift arrangements
      Drugs policy
      Assessment of skills competency as relevant to that                 *
      discipline
      Assessment of medical devices competency as relevant to             *
      that discipline
      Information on and meeting with named educational
      supervisor/clinical supervisor
      Information on educational facilities
      Information on where to go for help
      (mentoring/physical/support)
      Speciality/clinical guidelines/protocols
      Trust resuscitation arrangements
      A job description for each grade of doctor, including the
      limits of their authority and responsibility
      Details of limits to postholders authority and responsibility
      Details of access to senior advice, supervision and
      assistance
      Details of hospital communication/bleep systems
      Details of access to Trust Policies and Procedures.

     * This may entail assessment based on written evidence

3.   Roles and Responsibilities

     3.1    Medical Director

            •      It is the responsibility of the Medical Director to ensure that all junior
                   doctors in training are appropriately inducted to enable them to
                   undertake their duties competently and to protect their own well-being.
                   The Medical Director delegates this responsibility to the Post
                   Graduate Clinical Tutor.

     3.2    College/Specialty Tutors

            •      Ensure that the junior doctor attends the Generic Trust Induction
                   Programme for Doctors in Training (see appendix 2) within 8 weeks
                   after commencing employment. If appropriate they should attend the
                   F1 professional development weekly programme during the induction
                   period and be encouraged to attend the Shadowing course (see
                   appendix 3)
            •      Ensure that if the individual has been unable to attend the above that
                   they attend the Trust’s Mandatory Training day within 8 weeks after
                   commencing employment.
            •      Ensure that a robust local specialty specific induction process is in
                   place

                                                                                          15
      •      Forward a copy of the checklist for local speciality specific induction to
             OD and Training for recording purposes
      •      Maintain records of local induction for new junior doctors.

3.3   Junior Doctor

      •   Ensure that they attend the Generic Trust Induction Programme for
          Doctors in Training (see appendix 2) within 8 weeks after commencing
          employment. If appropriate they should attend the F1 professional
          development weekly programme during the induction period and be
          encouraged to attend the Shadowing course (see appendix 3)
      •   They must inform their educational supervisor if they are unable to
          attend, and they must ensure that they attend the next available Trust’s
          Mandatory Training day within 8 weeks after commencing employment
      •   Contact the Trust’s Mandatory Training Co-ordinator to arrange a date to
          attend
      •   Actively engage in local induction
      •   Keep a record of their attendance, and sign off any paperwork as
          instructed to ensure a permanent record is kept.

3.4   Post Graduate Clinical Tutor

      •      Ensure that the Trust offers an appropriate Trust induction process for
             junior medical staff, which is reviewed on an annual basis
      •      Assist in ensuring that all junior doctors complete the induction
             process, and that clinical/educational supervisors are aware of the
             process.

3.5   Clinical Tutor’s Office

      •      Co-ordinate and administer the Generic Induction Programme for
             Doctors in Training
      •      Ensure that all junior doctors attend the Generic Induction Programme
             for Doctors in Training and if appropriate the F1 Shadowing
             Experience (see appendix 2 and 3) within 8 weeks after commencing
             employment
      •      Maintain attendance lists and update shared spreadsheet
      •      Maintain records of the content of each induction session.
      •      Inform the Clinical Tutor monthly of any junior doctors for whom local
             speciality specific induction sign off sheet has not been received. For
             F1/F2 junior doctors this will be the Foundation Programme co-
             ordinator. For all other junior doctors this will be through the Clinical
             Tutor’s office for junior doctors on formal rotations, but must be left up
             to the relevant specialty to arrange if on a short term or locum basis.

3.6   Medical Staffing

      •      Input all details of new doctors in training onto the Intrepid system and
             the in-house spreadsheet.
      •      Provide lists of all new starters to Post Graduate Clinical Tutor’s office
             for use in construction of attendance lists for the induction process.



                                                                                    16
           •      Write to all new starters with starter information, which will include
                  information about the induction process as provided by the Clinical
                  Tutor’s office.

     3.7   OD & Training

           •   Contact those who do not attend within one week of the induction date to
               ensure they attend the next available Mandatory Training day if they have
               not already done so
           •   If requested book the junior doctor onto the next available Mandatory
                Training day
           •   Update shared spreadsheet
           •   Write to each participant and send a separate copy to the Clinical Tutors
               Office to forward to the relevant Clinical Supervisor
           •   Update shared spreadsheet as to whether the individual attended the
               above training or not.
           •   Update shared spreadsheet on receipt of local specialty specific induction
               sign off sheet

4.   Process for ensuring completion of all aspects of the programme within
     specified timescales

     The Trust’s Clinical Tutors Office has a responsibility to ensure that sufficient and
     timely Generic Induction Programmes for Doctors in Training are scheduled to meet
     the demand of incoming new starters.

     The Personnel Department will ensure that new employees and their Clinical
     Supervisors are notified in writing of the date of the Generic Induction Programmes
     for Doctors in Training in advance of their commencing of employment to ensure
     attendance within 8 weeks of their start date.

     The Clinical Tutors Office follows up non-attendance promptly and ensures that the
     junior doctors contacts the Mandatory Training Co-ordinator to arrange to attend the
     Trust’s Mandatory Training day.

     The OD & Training Department monitors attendance of junior doctors at Mandatory
     Training days and notifies the Clinical Tutors Office as to whether the individual has
     attended or not.

     The College/Specialty Tutor ensures that a relevant specialty specific induction is
     scheduled for the new junior doctor. This is documented and signed off and copies
     kept by both by the individual junior doctor and the College Tutor or Clinical
     Supervisor.

     The junior doctor is responsible for maintaining records of their local specialty
     specific induction.

5.   Process for ensuring all new junior doctors are booked onto the Generic
     Induction Programmes for Doctors in Training

     It is the responsibility of the Personnel Department to forward to all new starters
     information about their induction to the Trust.


                                                                                        17
     It is the responsibility of the College/Specialty tutor to ensure that their junior doctor
     attends the Generic Trust Induction Programme for Doctors in Training and, if not
     the next available Mandatory Training Day.

6.   Process for ensuring all new junior doctors attend induction

     Attendance at induction is a mandatory requirement in line with Trust policy.
     Failure to attend induction or mandatory training within 8 weeks of start date may
     result in the junior doctor being withdrawn from clinical duties and payment being
     withheld. This will be in consultation with the Clinical Tutor.

7.   System by which attendance at induction is recorded and co-ordinated
     centrally

     Attendance at the Generic Induction Programmes for Doctors in Training or
     Mandatory Training is recorded on the shared spreadsheet. A certificate of
     attendance will be awarded at the end of the induction process.

     Completion of local specialty specific induction is recorded by the junior doctor and
     the College Tutor or Clinical Supervisor.

8.   Method of evaluating the effectiveness of induction

     The content of the Trust’s Generic Induction Programmes for Doctors in Training
     day is reviewed on an annual basis by the Postgraduate Clinical Tutor. New junior
     doctors are asked to complete an evaluation form at the end of the session. These
     are returned to the Clinical Tutors Office for collation and then passed back to each
     trainer/facilitator for information and if necessary take action.

9.   Process for monitoring the effectiveness of all of the above
     A report detailing those Junior Doctors who do not attend the generic induction
     programme will be sent by the OD&T Department to the Director with responsibility
     for Human Resources and to the Trust Board , on a quarterly basis.as part of the
     HR Report.

     The Trust will collect information from staff in post when attending training events in
     order to fulfil its legal obligations and in accordance with the Race Equality and the
     Disability Equality duties.

     Compliance with this Policy will be monitored annually by inclusion in the annual
     Postgraduate Medical Education report and within the quality assurance processes
     of the Foundation School and developing Specialty Schools in line with PMETB QA
     reporting.




                                                                                            18
                                                                          Appendix 1a

               GATESHEAD HEALTH NHS FOUNDATION TRUST

             Generic Induction Programme for Doctors in Training

               Venue – Lecture Theatre, Education Centre, QEH
                      Date – first Wednesday in August



7.30am    Arrival & Breakfast – Rooms 9 & 10
          (During this hour, please ensure to meet with staff health and personnel
          representatives. Please bring the following: GMC Certificate, National
          Insurance Number, July Payslip. P45, Birth Certificate and Hepatitis B
          Status)


9.00am    Welcome & Introduction
          Clinical Tutor


9.15am    Fire Safety



9.45am    Chaplains


10.00am   Hospital at Night


10.30am   COFFEE BREAK


10.45am   Risk Management
          I


11.15am   IT session



11.30am   Infection Control

12 noon   Medical Devices

12.15pm   CLOSE




                                                                                     19
                  Gateshead Health Foundation Trust
         Generic Induction Programme for Doctors in Training

                First Thursday and Friday in August

                                  Group A

                        Lunch: 12.30 – 13.30pm
             (IT Training Room available 12.30 – 13.30pm)




1.30pm      Resus Training

2pm         Safeguarding Children

2.30pm      Coffee

2.45pm      Pathology/Transfusion

3.45pm      Manual Handling

4.00pm      Occupational Health

                                  Group B

                        Lunch: 12.30 – 13.30pm
             (IT Training Room available 12.30 – 13.30pm)


1.30pm      Pathology/Transfusion

2.30pm      Coffee

2.45pm      Resus Training

3.15pm      Safeguarding Children

3.45pm      Occupational Health

4.00pm      Manual Handling




                                                               20
                                                          Appendix 1b

                GATESHEAD HEALTH NHS FOUNDATION TRUST

            FOUNDATION DOCTOR SHADOWING/INDUCTION COURSE
2 weeks Commencing last Tuesday in July
Tuesday 29th July


08.00 – 10.00    Personnel & Occupational Health Issues


10.00 – 10.15    Welcome
                 Implementation Manager

10.15 – 10.30    Library Information
                 Trust Librarian


10.30 – 10.40    Coffee


10.40 – 11.10    Endoscopy
                 Senior Sister

11.10 – 11.30    IT Introduction
                 Head of IT

11.30 – 12.30    Pharmacy
                 Clinical Service Manager

12.30 – 13.00    Manual Handling
                 Clinical Ergonomics

13.00 – 14.00    LUNCH with current F1 Doctors



14.00 – 17.00    Shadow current F1 Doctors




                                                                  21
                 GATESHEAD HEALTH NHS FOUNDATION TRUST

              FOUNDATION DOCTOR SHADOWING/INDUCTION COURSE

Wednesday 30th July


09.00 – 10.00     Infection Control
                  Consultant in Microbiology

10.00 – 10.15     Needle Stick Injuries
                  Nurse Practitioner


10.15 – 10.30     Coffee


10.30 – 11.30     Radiology Introduction



11.30 – 13.00     Pathology – Requests/Blood Transfusion/Death Certificate &
                  Cremation Forms


13.00 – 14.00     LUNCH with Educational Supervisors

14.00-14.30       Hospital at Night


14.30 – 17.00     Portfolio Management/Policies & procedures/ Assessment Tools
                  Clinical Tutor
                  Foundation Programme Tutor




                                                                               22
                     GATESHEAD HEALTH NHS FOUNDATION TRUST

             FOUNDATION DOCTOR SHADOWING/INDUCTION COURSE

Thursday 31st July

09.00 – 17.00         ALERT + BLS & DEFIBRILLATION OR SHADOWING

Friday 1st August

09.00 – 17.00         ALERT + BLS & DEFIBRILLATION OR SHADOWING

Monday 4th August

09.00 – 12.30         Shadowing

12.30 – 13.30         Pharmacy
                      Clinical Service Manager

13.30 – 14.00         Food Hygiene

14.00 – 14.30         Medical Devices

14.30 – 15.15         Waste Management

15.15 – 15.30          Coffee

15.30 – 17.00          Shadowing

Tuesday 5th August

09.00 – 10.00         Fire Safety

10.00 – 10.30         Risk Management

10.30 – 10.40         Coffee

10.45 – 11.15         Equality & Diversity/Equal Opportunities

11.15 – 11.45         Safeguarding Children

11.45 – 12.15         Complaints
                      Complaints Manager

12.15 – 12.45         Bullying & Harassment

12.45 – 13.30         LUNCH

13.30 – 17.00         Shadowing




                                                                  23
                                                                            Appendix 1c




                        Mandatory Training Programme


08:55 - 09:00             Welcome & Introduction

09:00 - 09:30             Risk Management & Incident Reporting

09:30 - 09:45             Safeguarding Vulnerable Adults

09:45 - 10:15             Safeguarding Children

10.15 – 10.45             Manual Handling

10:45 - 11:00             Tea/Coffee

11.00 – 11.30             Introduction to Fire Safety in Hospitals

11.30 – 12.00             Equality, Diversity & Human Rights

12.00 – 12.30             Infection Prevention and Control (non clinical)
                          (Held in rooms 9 & 10)

Non Clinical staff may leave after this session at 12.30

12.00 – 13.00             Lunch Break

13.00 – 13.45             Infection Prevention & Control (clinical)

13.45 – 14.15             Food Hygiene

14.15 – 15.15             Basic Life Support/Transfusion

15.15 – 16.15             Basic Life Support/Transfusion



All sessions will be held in the Lecture Theatre with exception to Infection
Prevention & Control (non clinical) and Basic Life Support which will be held in
Rooms 9 & 10




                                                                                    24
                                                                                       Appendix 1d

                       GATESHEAD HEALTH NHS FOUNDATION TRUST

                          Doctors in Training Local Induction Checklist

    Name:                                     Specialty:

    Job Title:                                Base:

    The new doctor in training and educational / clinical supervisor should discuss the
    following topics during the first 2 weeks of employment. It is hoped that this checklist will
    help the new doctor settle in more quickly and enable them to do their job effectively.
    (Please write N/A where not applicable).

                                               Date                Educational /            Trainee
Personnel/Pay Arrangements                     Completed           Clinical Supervisor      Signature
                                                                   Signature
Payslips and time sheets
Aware of Trust policies, entitlements,
arrangements for annual leave, sick leave
and flexible working
Trade Union membership (eg BMA) and
personal indemnity – how to contact
                                               Date                Educational /            Trainee
Personal Development                           Completed           Clinical Supervisor      Signature
                                                                   Signature
Clinical supervision, appraisal and RITA
requirements
Local study leave entitlements,
arrangements and procedures
Staff Development Prospectus
Arrangements for Continuing Professional
Development and in placement teaching
Advised of Educational supervisor and
Clinical supervisor
                                               Date                Educational /            Trainee
Domestic Arrangements                          Completed           Clinical Supervisor      Signature
                                                                   Signature
Tour of department/ward
Aware of staff amenities: staff
restaurants/cafes, car parking, car park
permits, discount travel scheme, nursery
and play den
Smoke free policy
                                               Date                Educational /            Trainee
SafeCare                                       Completed           Clinical Supervisor      Signature
                                                                   Signature
Aware of arrangements for SafeCare within
the ward/Division
Aware of clinical audit and clinical
effectiveness
Aware of research governance issues

                                                                                                25
                                               Date        Educational /         Trainee
Department                                     Completed   Clinical Supervisor   Signature
                                                           Signature
Department structure and philosophy
Telephone bleep system
Emergency telephone numbers
Location of key link departments
Introduction to key members of staff
Main job responsibilities (including
expectations of the role and its parameters)
Sources of help and advice
Medication in common use within the
department
Accountability
Staff Charter – Rights and Responsibilities
Communications/team brief
                                               Date        Educational /         Trainee
Information Governance                         Completed   Clinical Supervisor   Signature
                                                           Signature
Handling information:
−     confidentiality
−     integrity
−     availability
Confidential Waste
Records Management –
Trust/Departmental policies
Use of passwords for accessing
information – how to set up
                                               Date        Educational /         Trainee
Health & Safety Arrangements/Security          Completed   Clinical Supervisor   Signature
                                                           Signature
Aware of fire policy, procedure, drills and
location of fire exits/extinguishers
Incident/accident reporting procedure
(Datix)
Department security
Role of security staff/on site policeman
Department keys/combination locks
Aware of on-call and prospective cover
arrangements – New Deal issues generally
                                               Date        Educational /         Trainee
Competence Assessment                          Completed   Clinical Supervisor   Signature
                                                           Signature
Completion of placement specific
competence assessment
Completion of medical devices assessment

         ON COMPLETION PLEASE RETAIN IN THE EMPLOYEE’S PERSONAL FILE
         A COPY MUST BE TAKEN AND RETURNED TO THE OD&T DEPARTMENT,
                             HANCOCK BUILDING



                                                                                    26
                                                                                  Appendix 2


                                                                          OD & Training Department
Our Reference                                                 Gateshead Health NHS Foundation Trust
                                                                           Queen Elizabeth Hospital
                                                                                        Gateshead
Direct line          0191 445 2991                                                        NE9 6SX
Main number          0191 482 0000
Fax                  0191 445 6184
E-mail               odandtraining@ghnt.nhs.uk


29 January 2010




Dear

Attendance at Trust Induction

I note from our records that you are employed by Gateshead Health NHS Trust but have
not attended a Trust Induction. As a result, you have been allocated a place on the next
available Induction, details of which are as follows:

Date          Time          Corporate / HCP      Venue


As you will be aware the Trust has a Corporate Induction policy PP30, which states that it
is a mandatory requirement that all employees must attend corporate and if appropriate
Health Care Professional Induction. Failure to do so may result in disciplinary action. It is
also a requirement that you complete an appropriate local induction and have an initial
CONTACT meeting and Personal Development Plan with your line manager.

In order to negotiate an alternative date, please contact OD and Training, on x3772 or via
odandtraining@ghnt.nhs.uk email.

Yours sincerely




Assistant OD & Training Manager




                                                                                              27
                                                                         Appendix 3


       Corporate Induction, Including All Healthcare Professionals


Day 1: Corporate Induction Programme


08.45 – 09.15    Coffee and Registration

09.15 – 09.30    Welcome

09.30 – 10.15    Meet the Chief Executive

10.15 – 10.30    Gateshead Lean

10.30 – 10.45    A Day in the Life of Gateshead Health NHS Foundation Trust (DVD)

10.45 – 11.00    Tea/Coffee

11.00 – 11.45    CONTACT Staff Appraisal Process (and Introducing the Union
                 Learning Representatives)

11.45 – 12.15    Human Resources Issues

12.15 – 13.00    Lunch

13.00 – 13.30    Risk Management: Incident Reporting and Investigation

13.30 – 14.30    SafeCare

14.30 – 14.45    Tea/Coffee

14.45 – 15.45    Introduction to Fire Safety in Hospitals

15.45 – 16.30    Waste management

16.30 – 16.45    Chaplains: Heavenly Bodies




                                                                                28
Day 2: Corporate Induction Programme


08.45 – 09.00    Coffee and Registration

09.00 – 09.15    The Role of the Staff Representative

09.15 – 10.30    Occupational Health and Safety at Work

10.30 – 11.00    Safeguarding Vulnerable Adults

11.00 – 11.15    Tea/Coffee

11.15 – 11.45    Safeguarding Children

11.45 – 12.15    Infection Prevention & Control

12.15 – 12.30    Information Governance

12.30 – 13.15    Lunch

13.15 – 14.15    Choosing Gateshead incorporating Compliments, comments,
                 concerns and complaints

14.15 – 14.45    Equality, Diversity and Human Rights

14.45 – 15.00    Tea/Coffee

15.00 – 16.30    Preventing Violence and Aggression




                                                                           29
Day 3: Healthcare Professional Induction Programme


08.30 - 09.00       Bank Staff Introduction Session*

08.45 – 09.00       Coffee and Registration

09.00 – 09.30       Healthcare Professional Introduction

09.30 – 10.15       Nutritional Issues

10.15 – 10.40       Positive Patient ID and Blood Transfusion

10.40 – 11.00       Respecting Religious and Cultural Needs

11.00 – 11.15       Tea/Coffee

11.15 – 12.00       Infection Prevention and Control

12.00 – 12.30       Radiation Awareness

12.30 – 13.15       Lunch

13.15 – 13.45       Medical Devices

13.45 – 14.45       Manual Handling/Basic Life Support

14.45 – 15.00       Tea/Coffee

15.00 – 16.00       Manual Handling/Basic Life Support

* Only applicable to staff employed on the Bank


Day 4: Healthcare Professional Induction Programme


08.45 – 09.00       Coffee and Registration

09.00 – 10.00       Admission through to Discharge

10.00 – 10.15       Record Keeping

10.15 – 10.30       Tea/Coffee

10.30 – 11.00       Medicines Management

11.00 – 11.30       Critical Care Outreach Team

11.30 – 12.00       Clinical Risk Management




                                                                30
                                    Appendix 4
Trust Induction Follow up Process




                                           31
                                                                                   Appendix 4a



                                                                            OD & Training Department
Our Reference                                                   Gateshead Health NHS Foundation Trust
                                                                             Queen Elizabeth Hospital
                                                                                          Gateshead
Direct line         0191 445 2991                                                           NE9 6SX
Main number         0191 482 0000
Fax                 0191 445 6184
E-mail              odandtraining@ghnt.nhs.uk


29 January 2010




Dear

Cancellation of place at Corporate Induction: INSERT DATE



I note from our records that you recently cancelled your place on the above Induction
days.

PP30 Induction Policy states that:

“it is a mandatory requirement that all employees must attend corporate and if appropriate
Health Care Professional Induction. Failure to do so may result in disciplinary action being
taken against either the individual or their manager.“

Please contact OD and Training on x3772 or odandtraining@ghnt.nhs.uk to arrange an
alternative date.

I would appreciate it if you could give this matter your urgent attention.


Yours sincerely




Assistant OD & Training Manager




                                                                                                32
                                                                                  Appendix 4b


                                                                            OD & Training Department
Our Reference                                                   Gateshead Health NHS Foundation Trust
                                                                             Queen Elizabeth Hospital
                                                                                          Gateshead
Direct line         0191 445 2991                                                           NE9 6SX
Main number         0191 482 0000
Fax                 0191 445 6184
E-mail              odandtraining@ghnt.nhs.uk


29 January 2010




Dear

Non attendance at Corporate Induction: INSERT DATE

I note from our records that you were due to attend the above Induction days and did not
attend.

PP30 Induction Policy states that:

“it is a mandatory requirement that all employees must attend corporate and if appropriate
Health Care Professional Induction. Failure to do so may result in disciplinary action being
taken against either the individual or their manager.“

Please contact OD and Training on x3772 or odandtraining@ghnt.nhs.uk to arrange an
alternative date.

I would appreciate it if you could give this matter your urgent attention.


Yours sincerely




Assistant OD & Training Manager




                                                                                                33
                                                                                    Appendix 4c


                                                                            OD & Training Department
Our Reference                                                   Gateshead Health NHS Foundation Trust
                                                                             Queen Elizabeth Hospital
                                                                                          Gateshead
Direct line         0191 445 2991                                                           NE9 6SX
Main number         0191 482 0000
Fax                 0191 445 6184
E-mail              odandtraining@ghnt.nhs.uk



29 January 2010




Dear

Missed session(s) at Trust Induction: INSERT DATE

I note from our records that you failed to attend the following session(s) at Induction:

SESSION TITLE                                                   TIME

SESSION TITLE                                                   TIME

As you will be aware the Trust has a Corporate Induction policy PP30, which states
that it is a mandatory requirement that all employees must attend corporate and if
appropriate Health Care Professional Induction. Failure to do so may result in
disciplinary action. It is also a requirement that you complete an appropriate local
induction and have an initial CONTACT meeting and Personal Development Plan
with your line manager.

Please contact OD and Training on x3772 or odandtraining@ghnt.nhs.uk to arrange an
alternative date.

Please be aware that your Induction attendance will remain incomplete until you have
attended the above session(s).

I would appreciate it if you could give this matter your urgent attention.

Yours sincerely




Assistant OD & Training Manager




                                                                                                34
                                                                 Appendix 4d
                      Local Induction Follow Up Process



  Run monthly starters
         list


                                                                 No further
     Record receipt of               Confirmation         Yes
                                                                   action
    confirmation of local             received?                   required
          proforma




    Send first reminder
    letter to appointing
    manager for staff in             Confirmation         Yes
     post more than 2                 received?
            weeks




  Send second reminder
   letter to appointing              Confirmation         Yes
  manager 2 weeks after               received?
       first reminder




Produce monthly report for
   appointing managers               Confirmation          Yes
 detailing staff (permanent           received?
 and temporary) for whom
local induction confirmation
         not received




    Produce quarterly
   report detailing non-             Confirmation          Yes
  compliance with policy              received?
  for Director of HR and
      HR Committee



    Escalate to Senior
          Team

                                                                          35
                                                                               Appendix 5

                    GATESHEAD HEALTH NHS FOUNDATION TRUST

Employee Induction Checklist


Name:                                     Ward/Department:

Job Title:                                Base:


The new employee and line manager/supervisor should discuss the following topics during
the first 2 weeks of employment. It is hoped that this checklist will help the new employee
settle in more quickly and enable them to do their job effectively. (Please write N/A where
not applicable).


                                        Date        Line Manager/       Employee
Personnel/Pay Arrangements              Completed   Buddy               Signature
                                                    Signature
Payslips
Hours of work/flexible working
arrangements
Annual leave arrangements
Completion of Time Sheets
Expenses claims/lease car
arrangements
Notifying sickness/certification
procedures
Trade Union representatives –
who they are and how to contact

                                        Date        Line Manager/       Employee
Domestic Arrangements                   Completed   Buddy               Signature
                                                    Signature
Location of toilets
Location of local rest areas
Location of staff restaurant/cafes
Arrangements for coffee breaks
Location of staff changing facilities
No smoking policy
Location of shop
Car parking arrangements
Car parking permits




                                                                                        36
                                       Date        Line Manager/   Employee
Department                             Completed   Buddy           Signature
                                                   Signature
Department structure and
philosophy
Telephone bleep system
Emergency telephone numbers
Tour of department/base
Location of key link departments
Location of department notice
boards
Introduction to key members of
staff
Main job responsibilities (including
expectations of the role and its
parameters)
Job description and KSF outline
Sources of help and advice
Medication in common use within
the department
Accountability
Staff Charter – Rights and
Responsibilities
Communications/team brief
Answering telephone enquiries
Internal post
Code of Connection – how to
apply for an e-mail account
Computer system, how to access
email, Intranet and Internet
Requests for stationery/supplies
Dates of departmental meetings
Meeting Rooms and how to book
them
Dress code

                                       Date        Line Manager/   Employee
Personal Development                   Completed   Buddy           Signature
                                                   Signature
Explanation of Investor in People
and culture of learning
Initial CONTACT meeting
arranged within one month of
appointment, which will involve
explanation of the KSF/CONTACT
process
Clinical supervisor/supervision
arrangements
Buddy/preceptorship
arrangements
Mentor including arrangements
Minimum period of supervised
practice
                                                                               37
Portfolio building (RED file)
Study Leave arrangements
Staff Development Prospectus
Arrangements for Continuing
Professional Development

                                       Date        Line Manager/   Employee
Information Governance                 Completed   Buddy           Signature
                                                   Signature
Handling information:
−     confidentiality
−     integrity
−     availability
Confidential Waste
Records Management –
Trust/Departmental policies
Use of passwords for accessing
information – how to set up

Health & Safety                        Date        Line Manager/   Employee
Arrangements/Security                  Completed   Buddy           Signature
                                                   Signature
Health & Safety responsible
persons
Manual handling as per risk
calculation tool in Staff
Development Prospectus
Personal copy of fire policy
Fire Policy
Local fire drills
Location of fire exits/extinguishers
Staff Safety Policy
Incident/accident reporting
procedure/Datix system
Department security
Role of security staff/on site
policeman
Department keys/combination
locks
Provision of uniforms/protective
clothing
Laundry arrangements for uniform/
protective clothing
Patient property – documentation/
disclaimer/property lists
Personal property
Obtain ID badges
Explanation of Mandatory Training
Corporate and Local
H&S Training applicable to the
risks of the job


                                                                               38
Please confirm that new staff have been instructed in the safe use of equipment
associated with their role

Instructions given for the        Date         Line Manager/      Employee
Following Equipment (please                    Buddy              Signature
list)                                          Signature




                                                                                  39
Please inform all new staff of their responsibility to attend the following training as
part of their induction and book their place as soon as possible

                                      Date           Line Manager/       Employee
Mandatory Training                    Booked         Buddy               Signature
                                                     Signature
Corporate Induction (inc. Fire)
Moving and Handling
Violence and Aggression
Please list other areas of mandatory training relevant to your grade. (continue overleaf if
necessary




                                                                                          40
 The following policies are available on the Trust Intranet and within your department.
 Please sign and date that you have read and understood those, which are relevant to your role.

 The responsibility for identifying policies relevant to the post lies with the line manager/supervisor.
 (Please tick)

 The responsibility for reading and seeking clarification of the relevant procedures lies with the
 individual.

 Policies and procedures are constantly being added to, revised and updated, therefore cross
 reference should be made with the intranet site, which lists the most current and up to date
 information.
                           Policies and Procedures – Personnel Policies

                                                         Tick        Signature            Date
PP01     Disciplinary Procedure
PP02     Grievance Procedure
PP03     Protection of Pay and Conditions of Services
PP04     Redundancy and Redevelopment Policy
PP05     Interim Principles for Industrial Relations
PP06     Filling of Posts Policy
PP07     Employees Working in other Organisations
PP08     Work Experience Policy
PP09     Authorisation of Leave Policy
PP10a    Recruitment and Selection policy/procedures
PP10b    Recruitment and Selection of Consultant
         Medical Staff
PP10c    Appointment and Employment of Locum
         Medical Staff
PP11     Managing Sickness Absence
PP12     Relocation Expenses Policy
PP13     Disputes Procedure
PP14     Equal Opportunities in Employment Policy
PP15     Employment Break
PP16     Job Share Policy
PP17a    Prevention of Harassment in the Workplace
         Policy
PP17b    Dealing with Harassment and Bullying in the
         Workplace
PP18     Flexible Working Policy
PP19     Employment Policy Relating to CRB
         Disclosures
PP20     Standards of Business Conduct for NHS
         Staff
PP21     Equality and Diversity Policy
PP22     Employment Policy on Protection Against
         Infection with Blood Borne Viruses
PP23     Retirement Arrangements
PP24     Maternity/Adoption/Maternity Support
         (Paternity) Policy
PP25     Mandatory Training Day Policy
PP26     Access to NHS Care Records Registration
         Authority Smartcards

                                                                                                 41
PP28a     Consultants Clinical Excellence Awards
          Scheme
PP28b     Associate Specialists Discretionary Points
          Scheme
PP28c     Staff Grades Optional Points Scheme
PP29      Education Training and Development Policy
PP30      Induction Policy
PP32      Job Matching & Evaluation Procedure
PP33      Senior Medical Staff Appraisal Policy
PP34      Working Time Regulations Policy
PP35      Raising Concerns at Work
PP36      Fraud Policy
PP37      CONTACT Policy
PP38      Prevention of Alcohol, Drug & Substance
          Misuse in the Workplace
PP39      Well-being at Work Policy
PP40      Reference Policy
PP41      Professional Regulation Policy
PP42      Work Attire and Appearance

                          Policies and Procedures – Risk Management Policies

                                                       Tick   Signature        Date
RM01          Management of Risk Strategy
RM02          Health and Safety Policy
RM04          Incident Reporting and Investigation
              Policy
RM05          Reporting of defects Policy
RM06          Manual Handling Policy
RM07          Display Screen Equipment Policy
RM08          Control of Substances Hazardous to
              Health
RM10          Violence at Work Policy
RM11          Security Policy
RM13          Provision and Use of Work Equipment
              Policy
RM14          First Aid at Work Policy
RM15          Latex Policy
RM17          Personal Protective Equipment at Work
              Policy
RM18          Electrical Equipment Protocol
RM19          Lifting Equipment Protocol
RM20          Toy Safety Protocol
RM21          Complaints Policy
RM22
Consent
Form 1        Consent to Treatment Policy
Consent
Form 2
Consent
Form 3
Consent
Form 4
                                                                                      42
RM23    Claims Management Policy
RM24    Inter and Multi Agency Information
        Exchange Policy
RM25    “Safe” Hot Water and Surface
        Temperature Protocol
RM26    Ventilation Systems Protocol
RM27a   Resuscitate Policy
RM27b   Do Not Resuscitate Policy
RM28    Policy for Carrying Out Building and
        Engineering Works
RM29    Superceded by RM52
RM30    Policy for the Procurement,
        Management and Use of Medical
        Devices
RM31    Procedure for Provision of Donor
        Organs for Transplantation
RM32    Policy for Withholding Treatment from
        Violent and Abusive Patients/Visitors
RM33    Guidelines for the Use of MEWS Chart
RM34    Superceded by RM52
RM35    Replaced by RM04
RM36    Blood Transfusion Policy
RM37    Smoke Free Hospital Policy
RM38    Intellectual Property Policy
RM40    Patient Identification Policy
RM41    Young People at Work Policy
RM42    Driving at Work Policy
RM43    Correct Site Surgery Policy
RM44    Local Policy – Authorised Users of
        Medical Devices
RM45    Training Policy for Medical Devices
RM46    Local Policy – Training Required by
        Locum, Bank and Agency Staff
RM47    Policy for Patients Discharged from
        Hospital with a Medical Device
RM48    Local Risk Management Policy &
        Procedure
RM49    Being Open Policy
RM50    Slips Trips and Fall Policy
RM51    Learning from Experience Policy
RM52    Supervision of Medical Staff in Training
RM53    Trustwide Validation of Results Policy
RM54    National Confidential Enquiries Policy
RM55    Nasogastric Feeding Policy
RM56    Ultrasound Risk Management Policy
RM57    Massive Blood Transfusion Policy
RM58    Parenteral Infusion Pumps Policy




                                                   43
                 Policies and Procedures - Specialist Risk Management Policies

                                                        Tick   Signature    Date
Safe Working with Asbestos Policy
Construction Design and Management
Electricity at Work Policy
Flammable and Explosive Substances Policy
Medical/Industrial Gases Policy
Noise at Work Policy
Pressure Systems Policy
Safe Management and Use of Ladders etc Policy
Safe Management and Use of Sterilisers Policy
Confined Spaces Policy
Legionella Policy
Ionising Radiation/Radiation Protection Policy

                           Policies and Procedures – Operational Policies

                                                        Tick   Signature     Date
OP01       Hospitality, Gifts and Inducements Policy
OP02       Recognition of Long Service Policy
OP03       Car Park Management Policy
OP04       Charitable Funds Policy
OP05       Laundering and Uniforms Policy
OP06a      Information Security Policy
OP06b      It Security Policy
OP07       Completion of Staff Expenses Forms Policy
OP08       Issuing of Condoms (Including to persons
           under 16 years)
OP09       Provision of Injecting Equipment for under
           16 years olds
OP10       Records Management Policy
OP11       Private Patients Practice
OP12       Patient Access (Waiting List – Waiting
           Times) Policy
OP13       Discharge Policy
OP14       Data Quality Policy
OP15       Freedom of Information Policy
OP16       Replaced by OP38
OP17       Internet, Intranet & Email Policy
OP18       Copying Letters to Patients Policy
OP19       Pre Assessment Policy
OP20       Replaced by OP38
OP21       The Combined Critical Care Unit Admission
           and Operational Policy
OP22       Fax Machine Policy
OP23       Replaced by OP38
OP24       Critical Care Outreach Team Policy
OP25       Handling Living Wills
OP26       Combined Maternity/Community Services
           Policy on Breastfeeding

                                                                                    44
OP27       Policy Standards Protocol
OP28       Clinical Photography
OP29       Safeguarding Patient Privacy and Dignity
           Policy
OP30       Clinical Supervision Policy
OP31       Operational Policy for the Use of the
           Medical Devices Library
OP32       Trust Interpreting Policy
OP33       Bed Management and Escalation Policy
           2005
OP34       Perioperative Fasting Guidelines
OP35       Rapid Release of Bodies Policy

OP36       Policy for Commercial Contracts and
           Service Level Agreements
OP37       Taxi Policy
OP38       Operating Theatre Performance Scheduled
           Sessions Policy
OP39       Health Records Keeping Policy
OP40       Patient Information Protocol
OP41       Central Venous Line Policy
OP42       Policy for Reporting to External Agencies
OP43       Best Practice Policy
OP44       Missing Patient Policy
OP45       Safeguarding Adults Policy
OP46       Catering Hygiene Policy
OP47       Temporary Staffing Pack

                       Policies and Procedures – Nursing Specific Guidelines

                                                       Tick   Signature        Date
Enrolled Nurses
Clinical Supervision Guidelines
Managing Poor Performance
Annual Leave Guidelines for Nurses
Payment for Night Duty Guidelines
Uniform Replacement

                               Policies and Procedures – Drug Policies

                                                       Tick   Signature        Date
DP01       Ordering, Storage, Prescribing and
           Administration of Medicines
DP02       Ordering Supply of Medicine
DP03       Transport of Medicines
DP04       Storage of Medicines
DP05       Standards of Prescribing
DP06       Prescribing of Unlicensed Medicines
DP07       Administration of Medicines – General
DP08       Administration of Medicines – Except by
           the Parenteral Route
DP09       Ward Preparation and Administration of

                                                                                      45
       Medicines – Parenteral Therapies
DP10   Procedure for the Preparation and
       Administration of Medicines for I.V. Use in
       Theatres
DP11   Procedure for Medicines Brought into
       Hospital by Patients
DP12   Procedure for Self-Medication by Patients
DP13   Disposal of Medicines
DP14   Controlled Drugs
DP15
DP16
DP17
DP18   Transfer for Prescribing Between Hospitals
       and General Practitioners
DP19   New Drug Requests
DP20   Patient Group Directions
DP21   Point of Discharge Policy
DP22   Non-medical prescribing policy
DP23   Allergy Documentation
DP24   Pharmacy Aspects of Clinical Trials
DP25   Dispensing /Checking of Medicines &
       Supervision within the Pharmacy
       Department
DP26   Ward Preparation and Administration of
       Medicines – Epidural Therapies Policy
DP27   Private Prescription Policy
DP28   Use of Intravenous Heparin Flush Solutions

               Policies and Procedures Infection Prevention and Control

                                                     Tick   Signature     Date
IC1    Infection Control Policy
IC2    Personal Protective Clothing in Clinical
       Practice
IC3    Universal Precautions for the Control of
       Infection
IC4    Hand Washing Policy
IC5    Immunisation Policy
IC6    Isolation Policy
IC7    Protecting Staff and Patients against
       Infection with Blood Borne Viruses
IC8    Reducing Risks of Infection from Human
       Cadavers
IC9    Waste Disposal and Recycling Policy
IC10   Hospital Laundry Arrangements for Use
       and Fouled/Infected Linen
IC15   Cleaning and Disinfection Policy
IC16   Use of, Cleaning, Disinfection and
       Maintenance of Endoscopy Equipment
IC17   Decontamination of equipment prior to
       routine infection, servicing and repair and
       decontamination of equipment that is the
       subject of complaint or investigation
                                                                                 46
IC18   MRSA Policy: Policy for the Management
       of Methicillin (Flucloxacillin) Resistant
       Staphylococcus Aureus (MRSA)
IC19   Meningitis
IC20   Tuberculosis Control Plan
IC21   Management of Scabies
IC22   Transmissable Spongiform
       Encephalopathies (TSE) Agents: Safe
       Working and the Prevention of Infection
IC23   Guidelines for Enteric Infections exclusion
       from work for trust employees
IC24   Outbreak Management
IC25   Interim Influenza Pandemic Plan Infection
       Control Guides
IC26   Clostridium Difficile Policy
IC27   Blood Culture Policy (July 2008)
       Control of Infection Manual




                                                     47
                                                                                 Appendix 6



                                       Permanent staff
                                     Induction Flow Chart



                   Within 2 weeks
                   Local Induction
        •   Timetabled programme
            according to role
        •   Local introductions
        •   Complete induction checklist
        •   Complete relevant
            documentation
        •   Complete and return local
            induction pro forma
        •   Identify a named buddy                                Within 8 weeks
                                                          Attend Corporate Induction
                                                          and healthcare professional
                                                          induction if applicable




                                                       Within 4 weeks
                                                Identify priority areas for
                                                         induction
                                           •   Initial CONTACT meeting
Identify immediate                             including review of KSF outline
training needs and                         •   Identify development needs
arrange to attend relevant                 •   Continue to work with named
course                                         buddy to learn systems &
                                               processes
                                           •   Development activities




          6 months
   CONTACT Interim review
   • Review objectives &
     Personal Development
     Plan                                                  12 months
   • Feedback on                                   Annual CONTACT Review
     performance                                & progression through Foundation
   • Complete local                             Gateway if applicable
     induction workbook



                                                                                        48
                                                                                        Appendix 7

                                           Nurse bank staff
                                         Induction Flow Chart


                                                                          Days 1 – 14
                      Day 1                                             Local Induction

             Attend Corporate and                         •    Timetabled programme according to
            Healthcare Professionals                           role
                   Induction                              •    Local introductions
                                                          •    Complete induction checklist
                                                          •    Complete relevant documentation
                                                          •    Complete and return confirmation of
                                                               local induction pro forma
                                                          •    Identify a named buddy
                                                          •    Receive and complete induction
                                                               workbook
                                                          •    Receive nurse bank staff handbook




                                                          Identify priority areas for
    Identify immediate                                            induction
    training needs and
arrange to attend relevant                            •       Initial Team CONTACT
          courses                                             meeting including review of
                                                              KSF outline
                                                      •       Identify development needs
                                                      •       Continue to work with
                                                              named buddy to learn
                         Ward level                           systems & processes
                                                      •       Development activities
             Receive a local induction in each
             ward area and complete local
             induction checklist for bank staff




                                                              12 months
                                                      Annual CONTACT Review
         6 months                                  & progression through Foundation
  CONTACT Interim review                           Gateway
 • Review objectives &
   Personal Development
   Plan
 • Feedback on performance


                                                                                               49
                         Local Induction Checklist for Bank staff

This form is to be completed during your Orientation shift and countersigned by the
nurse in charge.

Name:                                       Band:
Date:

Orientation to ward area                                                Yes No
Shown around geographical ward area:

Location of Fire exits/ equipment:

Aware how to raise the alarm in the event of a suspected fire

Aware of role in the event of a fire

Location of Moving and Handling Equipment

Informed how to raise help in the case of an emergency:

Emergency Buzzer

Cardiac / Respiratory arrest

Storage of Local of Policies and Procedures:

Aware of the Hospital Bleep System and how to use it:

Serving of hot meals:

This must be provided by a cascade trainer and you will not be
able to serve meals from the Hot Trolley until this has been done.

Name of cascade Trainer:
Explanation re meal breaks re shift pattern:


Signature of nurse in charge:                                   Date:


Following completion of this form a copy will be required to be forwarded to:

Nichola Russell
Clinical Practice Matron
Trust HQ




                                                                                 50
                                                                             Appendix 8

                              Student induction process


Each division/department has its own local induction arrangements for students.



                Local Induction
     •   Timetabled programme
         according to role
     •   Local introductions
     •   Complete relevant induction
         checklist
     •   Complete relevant
         documentation
     •   Identify a named
         buddy/mentor/supervisor

                                                               Induction
                                                   Ensure attendance at student
                                                   induction programme. Attend 1
                                                   day Introduction to Moving and
                                                   Handling if required.




                                                 Identify priority areas for
                                                          induction
                                            •   Identify development needs
                                            •   Student continues to work with
                                                named buddy to learn systems
                                                & processes
                                            •   Student undertakes
                                                development activities




                                                                                    51
                                                                           Appendix 9
                            Volunteers local induction checklist

Name:                                               Date:
Ward:
Buddy:


Geography of Area                                   Date:
Fire Escapes                                        Date:
Fire-fighting Equipment                             Date:


Identification badge                                Date:
Confidentiality discussed                           Date:
Car parking                                         Date:
Dress & protective clothing                         Date:
Hygiene & hand washing                              Date:


Access to and Understanding of: (to be completed within initial 4 weeks)
Volunteers Policy
Dress Code
Communication & Reporting Structures
Hygiene & Hand-washing
Infection Control
Confidentiality Policy
Volunteer Guidelines
Grievance Policy
Complaints Policy
Child Protection
Protection of Vulnerable Adults




                                                                                  52
                                                                            Appendix 10

                                  Locum Medical Staff
                                  Induction Flow Chart


In Accordance with the Trust’s Policy on the Appointment and Employment of Locum
Medical Staff PP10c, the following should be completed for locum medical staff.




                       Day 1
                   Local Induction

            •   Issue generic information
                sheet (PP10c Appendix 9)
            •   Issue Directorate/specialty
                induction pack – refer to
                policy for details


                                                                 Locums are then asked to
                                                                 confirm on their time sheet
                                                                  that they have received
                                                                   appropriate induction




                                                         Authorising manager should the
       Trust must follow the                             verify this declaration before
      Code of Practice relating                          submitting the locum’s timesheet
          to performance                                 for payment
       assessment of locum
              doctors




                                                     If locum medical staff are
 Routine assessments of locum                        then appointed on a fixed
 consultant’s work should be carried                 term basis they should
 out by a senior clinician using                     attend corporate induction
 Appendix 10 of PP10c                                and receive an appropriate
                                                     local induction.




                                                                                       53
                                                                          Appendix 11

                                         Agency staff
                                     Induction Flow Chart


Agency nurses are not used widely across the Trust; however they are used occasionally
in Theatres and the Treatment Centre.



                                      Day 1
                                  Local Induction

              •       Issue agency booklet
              •       Complete relevant induction checklist
              •       Complete assessment competency form
              •       Complete and return confirmation of local
                      induction pro forma
              •       Identify any document immediate training
                      needs




                                        Temporary staff
                                     Induction Flow Chart



                                       Day 1
                                   Local Induction

                  •    Complete local induction checklist for
                       temporary staff
                  •    Complete and return confirmation of local
                       induction pro forma
                  •    Identify any document immediate training
                       needs




                          If temporary member of staff is to
                          be in post for more than 1 month
                               ensure individual attends
                                 corporate induction




                                                                                     54
                        Local induction checklist for temporary staff

 Name:

 Grade:

 Job Title:

 Ward/department/Directorate:

 Inducted by:

 Date:


                                Checklist                               Please tick
                                                                           when
                                                                        completed

Introduction to staff and orientation to wards/clinical
areas/departments

Expectations and limitations of the post

Familiarisation with equipment and procedures and appropriate
training requirements

Local emergency procedures and including fire and summoning help
in an emergency

Bleep system, resuscitation procedures

Emergency numbers: fire, arrest, security

Procedure for contacting on call manager and doctor

Local policies and procedures

Medication common to the area and patients group directives, where
applicable

Sources of help and advice

Mentorship




                                                                                      55
                                                                                   Appendix 12




Confirmation of Local Induction

This form should be signed off by the new employee’s Line Manager within two weeks of
the start of employment and a copy returned to OD and Training for recording purposes.


 Name:

 Job Title:

 Department/Location:

 Payroll Number:

I am satisfied that for CNST purposes, the above named member of staff has received
specific induction appropriate to the specialty in which they are working.

A full record of their local induction is available for audit purposes in their *personal
file/within the department (*delete as appropriate)


 Line Manager Signature:

 Line Manager Print Name:

 Employee Signature:

 Sponsor/Buddy Signature:

 Sponsor/Buddy Print Name:

 Date:

If it is a requirement of your post to develop policies and procedures you will be required to
attend Impact Assessment Training.

Please tick in the appropriate box whether this is required.

Yes

No




                                                                                            56

				
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