Withington Community Hospital Operating Manual

Manchester Community Health

Withington Community Hospital

Operating Manual

Version 2.6 August 2010

WCH Operating Manual version 2.6 August 2010

Contents
Contents................................................................................................................................ 3 Section 1 Introduction......................................................................................................... 4 1.1 Introduction .............................................................................................................. 4 1.2 WCH Management Team ......................................................................................... 4 Section 2 Accessing WCH.................................................................................................. 5 2.1 Hospital Opening Hours ........................................................................................... 5 2.2 Space Reservation and Usage ................................................................................. 5 2.3 Hospital Access........................................................................................................ 5 Section 3 Hospital Amenities & Facilities ............................................................................ 5 3.1 Hospital Amenities.................................................................................................... 5 3.2 Duty Manager / Bleep 300........................................................................................ 6 3.3 Security .................................................................................................................... 6 3.4 Facilities Management.............................................................................................. 6 3.5 Pharmacy ................................................................................................................. 6 3.6 Receipt & Distribution ............................................................................................... 6 3.7 Decontamination Service.......................................................................................... 7 3.8 Car Parking .............................................................................................................. 7 3.9 Seminar Rooms........................................................................................................ 7 3.10 Waste Management & Recycling............................................................................ 7 3.11 Transportation of Specimens.................................................................................. 7 3.12 Mobile Diagnostic Vans .......................................................................................... 7 Section 4 Staff .................................................................................................................... 8 4.1 Staff Induction .......................................................................................................... 8 4.2 ID Badges ................................................................................................................ 8 4.3 Uniform..................................................................................................................... 8 4.4 Professional Registration.......................................................................................... 8 Section 5 IT ........................................................................................................................ 8 Section 6 Internal Communication ...................................................................................... 8 Section 7 Patient Transport ................................................................................................ 8 Section 8 WCH Policies & Procedures ............................................................................... 9 8.1 Fire Procedure.......................................................................................................... 9 8.2 Resuscitation Policy & Procedure including Medical Emergency.............................10 8.3 Health & Safety / Risk Management ........................................................................10 8.4 Infection Prevention and Control .............................................................................10 8.5 Smoking ..................................................................................................................11 8.6 Treatment Centre Policies & Procedures.................................................................11 Section 9 Equipment & Medical Devices ...........................................................................11 Section 10 Governance .....................................................................................................12 10.1 Complaints ............................................................................................................12 10.2 Incident Reporting .................................................................................................12 10.3 Record keeping .....................................................................................................13 Section 11 Safeguarding ...................................................................................................13 Section 12 Patient Information...........................................................................................13 Section 13 Clinical Cleaning Schedules ............................................................................13 Section 14 Contacts ..........................................................................................................13

WCH Operating Manual version 2.6 August 2010

Section 1 Introduction
1.1 Introduction
Withington Community Hospital (WCH) is a multi-organisation site. Owned and operated by NHS Manchester (formerly Manchester PCT) which provides clinical accommodation to a range of NHS and Independent Sector healthcare organisations. This Operating Manual is for services and service providers using facilities at Withington Community Hospital and should be read in conjunction with other WCH policies and procedures which are all available on the WCH Intranet and WCH webpage on the NHS Manchester website http://www.manchester.nhs.uk/findyournearest/otherservices/withingtoncommunityhospital/wi thington_community_hospital.html Where this manual refers to service providers, this encompasses any organisation, department or service that has the right to work within Withington Community Hospital under a lease or license agreement. Where this manual refers to staff, this encompasses any member of staff from any service or service provider working within Withington Community Hospital. The WCH Management Team are employed by NHS Manchester and are responsible for managing the hospital infrastructure, and the co-ordination services operating within it. In addition, the Hospital has an on-site Facilities Management Team who are responsible for the cleaning and maintenance of WCH, an IT Team who offer dedicated IT support to staff and services on-site and a Receipt & Distribution function. Withington Community Hospital is departmentalised, some departments are leased by a single provider e.g., Urology, Sexual health and Palatine Sexual health. Where space is not leased to a single provider it can be licensed on a sessional basis. Below is a table outlining which organisations currently use which areas: Radiology UHSM Womens and Childrens UHSM & NHS Manchester Audiology / ENT UHSM & NHS Manchester Palatine Sexual Health NHS Manchester OPD UHSM, SMI, Christies, CMFT Therapies UHSM & NHS Manchester Sexual Health UHSM Treatment Centre / Cataracts UHSM, NHS Manchester, Charter Medical, CMFT Urology UHSM External Alliance Medical Services

1.2 WCH Management Team

The WCH Management Team are employed by NHS Manchester and are responsible for running the hospital and the services within it. Currently the WCH Management Team is comprised of: Tom Pickup Joyce Cooke Margaret Gardner Jane Woolley Doreen Benjamin General Manager - Withington Community Hospital Hospital Manager Deputy Hospital Manager Standards Co-ordinator Secretary to WCH Management Team 0161 217 3899 0161 217 3898 0161 217 3614 0161 217 3284 0161 217 3536

WCH Operating Manual version 2.6 August 2010

Section 2 Accessing WCH

2.1 Hospital Opening Hours
The hospital is open from 7.40am Monday Friday and from 9.00am at weekends and Bank Holidays. The majority of services operate between 8am and 5pm. Some services operate outside these hours by individual agreement.

2.2 Space Reservation and Usage

Providers either lease a whole department for their sole use or clinic space on a sessional basis. Where we do lease on a sessional basis the session times are 08:30-12:30 and 13:0017:00. Service providers are required to operate between these hours, with any provision outside of these hours being agreed with the Hospital Management Team. Service Providers must not overrun these session times without agreement from the Hospital Management Team. Any use of sessions outside of the agreed times is considered a breach of contract. Space can be booked on an ongoing, committed basis or on an ad-hoc basis. Booking and cancellation fees may be applicable depending on notice periods given. The Hospital Management Team must also be notified in writing when reserved space / rooms are no longer required. Please refer to the Space Reservation Policy for further information. The sub-letting of space between service providers is generally not permitted and can only be approved following discussion and agreement with the Hospital Management Team.

2.3 Hospital Access

The number of external entrances, for security reasons are kept to a minimum. Patients, staff and visitors will normally enter through the main entrance and reception area. A separate service entrance is located adjacent to R&D for goods and technical services such as refuse collection. There is access to the enclosed courtyard by the Womens and Childrens Department for patients and staff. All areas of the building and hospital site (including car parks) are designated No Smoking areas. Staff are not permitted to smoke on the hospital site. Emergency exits are available, are highly visible and only to be used for that purpose. Out of Hours access to the main building will be via a video entry system directly to the security office.

Section 3 Hospital Amenities & Facilities

Withington Community Hospital provides the following amenities, facilities and services to all service providers, patients and visitors who use WCH.

3.1 Hospital Amenities

Catering Catering facilities are available in the main entrance, next to the Cashiers office and is currently available from Monday - Friday 8.00am to 4.00pm. Vending machines are available outside of these hours. Cashiers Office The Cashiers office is open Monday to Friday 9.30am - 4.30pm (4pm on Fridays). The Cashiers office can refund patient travel costs (for patients on relevant DSS Benefits), 5
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patient wages, petty cash etc, please contact the Cashiers office for more information or if you have any questions Contact tel: 0161 217 3022. Health Information Point These include information leaflets and computer facilities to help patients find health information easily. These are situated in the main entrance, catering area and also halfway down the ground floor corridor. Please direct any patients who would like any further information about their health and well-being to these points, there are volunteers available most mornings to guide patients through the process and to help and advise them where possible. Info Desk The Info Desk is situated at the front of the hospital reception area and is staffed during hospital opening hours. The Info desk is not a reception. Staff meet and greet patients and visitors and direct them to appropriate services. Staff are also able to answer queries and questions about Withington Community Hospital. Quiet Room There is a multi-faith room available for patients and visitors to use, for quiet contemplation. The room can also be used by mothers for breast feeding.

3.2 Duty Manager / Bleep 300

The hospital provides a Duty Manager currently on site from 8am to 6pm, Monday to Friday. Outside of these hours, the PCT On Call Manager can be contacted via switchboard. The Duty Manager is available to deal with anything which cannot be dealt with by the service or to report ongoing problems or untoward incidents to.

3.3 Security
Withington Community Hospital has 24 hour security on site and the building and car parks are monitored by CCTV.

3.4 Facilities Management

WCH has its own on-site Facilities Management Team. To report any issues regarding the building or cleanliness of the building please phone the Helpdesk on 3333. The FM Team offer the following services Switchboard Post Portering Cleaning Linen & Laundry service Building fabric & Services Energy Management In addition there is an on-site engineering team.

Fire & Emergency assessment Ground maintenance FM Help desk Pest control Security Waste Management

3.5 Pharmacy
The Pharmacy is located in the main reception area next door to the cashiers office; it is open Monday to Friday between 9.00am to 5.30pm. The Pharmacy stocks a range of over the counter medicines and deals with prescriptions written by WCH services.

3.6 Receipt & Distribution

WCH provides a Receipt and Distribution service for all service providers. 6
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All service providers will ensure that their ordering/deliveries meet working requirements, whilst not exceeding their own storage facilities. The R&D department will not be able to offer a storage facility for goods other than stationery stock. The R&D department will co-ordinate the movement and timings of collections/deliveries to and from the site and interdepartmentally to minimise vehicular traffic, congestion and disruption to usual hospital activities.

3.7 Decontamination Service

WCH provides an off site decontamination service for all providers who require this. Service provider decontamination requirements should be discussed prior to commencement of the service.

3.8 Car Parking

Staff car parking is included in the hospital charges. All staff working in the hospital have the right to use the car park. Non-hospital staff, patients and visitors will be have to pay for onsite car parking. Car parking is currently priced at 2 per day.

3.9 Seminar Rooms

The Seminar Suite is available for all service providers and community groups to use for training, educations and general communications and meetings. Seminar rooms are not permitted to be used for any clinical activity. Fees are chargeable for external organisations and users and refreshments are available if booked prior to the meeting. Please see the Seminar Room Protocol for further information.

3.10 Waste Management & Recycling

WCH provides a clinical and domestic waste management and recycling service for all service providers. We provide all of the clinical and domestic waste sacks, as well as a storage, collection and disposal service. Service providers are required to provide their own sharps bins and these will be collected and disposed of accordingly by WCH. We provide facilities for the disposal of confidential waste. All domestic waste is taken off site and sorted for recycling including paper, cardboard and glass.

3.11 Transportation of Specimens

Specimens will be transferred from departments to a secure central collection point; each service provider is responsible for arranging the collection and delivery of specimens to the pathology laboratory for testing. Note the transport collection driver must have appropriate ID before they can collect specimens from this site.

3.12 Mobile Diagnostic Units

WCH has the facility to accommodate up to three Mobile Diagnostic Units. We provide a reinforced parking substructure for Units and offer dedicated IT, electrics and telephony.

WCH Operating Manual version 2.6 August 2010

Mobile Diagnostic Units must not be moved on or off site between 11pm 7am Monday Friday and 11pm 9am on Saturday Sunday and Bank Holidays.

Section 4 Staff
4.1 Staff Induction
All permanent staff working at Withington Community Hospital must undertake the half day induction, please contact WCH Management for details. Sessional or temporary staff must undertake an ad-hoc induction with a member of the Hospital Management Team or Head of Department prior to commencing duty.

4.2 ID Badges
All staff must have a visible WCH ID badge. ID badges are available from Security. The ID badge acts as a swipe card in and out of department areas and the car park. Staff can only access WCH out of hours on presentation of this badge.

4.3 Uniform
All staff must wear the uniform approved by their organisation. If no uniform is specified then clothing should be smart, clean, tidy and respectable.

4.4 Professional Registration

Service providers must ensure all staff have and maintain their professional registration and they adhere to mandatory training requirements.

Section 5 IT
WCH provides a standard IT infrastructure throughout the hospital; and a dedicated IT support service including on site technician, engineer and helpdesk. This is backed up by an off site team. If service providers have any specific IT requirements then they are responsible for providing any hard or software needed. However any upgrades to the WCH IT system must be undertaken by and in agreement with the WCH IT team. The WCH Intranet is available via an icon on the log-in page of the IT system. It includes electronic copies of all hospital policies and procedures, general hospital information, departmental information, Datix Incident Reporting System and links to other organisations.

Section 6 Internal Communication

All service providers are required to identify a named representative to be included on the email distribution list to cascade WCH information to all service providers and their employees. All service providers are required to send a representative to the monthly Heads of Department meetings and the regular Health & Safety meetings as well as attendance at any ad hoc meetings arranged by WCH Management. Minutes of these meetings will be distributed by email.

Section 7 Patient Transport

Service Providers are responsible for their patient from when they arrive at Withington Community Hospital until they are collected at the end of their appointment by hospital transport. Clinical staff must remain with the patient in their service area until they are collected. The ambulance will collect the patient from the service area. Patients must not be directed to wait at the main entrance. 8
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Section 8 WCH Policies & Procedures

There are a range of WCH policies and procedures which all staff are required to adhere to and are available on the WCH Intranet and WCH webpage on the NHS Manchester website http://www.manchester.nhs.uk/findyournearest/otherservices/withingtoncommunityhospital/wi thington_community_hospital.html WCH wide policies and procedures include: Whole Hospital Policy WCH Resuscitation Policy WCH Controlled Drugs Policy WCH Medicines Policy Fire Procedure Space Reservation Policy Seminar Room Booking Protocol IT Acceptable usage Policies Where issues are not covered by WCH specific policies then staff should refer to the policies of their own organisation.

8.1 Fire Procedure

Each service provider must follow the WCH Fire Procedure. Service providers are responsible for providing their staff with fire training and fire training updates. WCH provide to all staff working in WCH a fire induction as part of the induction half day. Evac-chair training is also provided to staff working on the first floor on an annual basis. Staff, patients and visitors must evacuate the building on hearing the continuous fire alarm. Each department area/service must identify a member of staff to act as Fire Marshal each session/day. The appointed Fire Marshal must clear their area and report to the Duty Manager on exiting the building. In the Theatres the alarm will not sound but a light will flash to alert staff of the need to evacuate. Ensure that you are aware of the location of the nearest fire exits, fire alarm points and extinguishers in your service area. The Fire Brigade do not attend WCH fire alarm calls automatically but will attend immediately they are notified there is a problem. The Duty Manager will confirm when the building can be re-entered following a fire evacuation. Each service area has an allocated a fire assembly point identify where yours is and plan your route so you know where to go in the event of a fire. A weekly fire alarm test is carried out on Wednesdays at 8.30 am. The alarm during the test is intermittent not continuous. There is also an annual fire evacuation test. There are evac-chairs located at the top of each stairway to be used by staff to evacuate patients who are unable to take the stairs themselves. Training on the use of these chairs is mandatory for clinical staff working on the first floor and is offered regularly and if you would like to be trained please contact WCH Management and this can be arranged.

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Clinical staff based on the 1st floor must undertake evac-chair training as the evacuation of their patients is their responsibility.

8.2 Resuscitation Policy & Procedure including Medical Emergency

Service providers must follow the Resuscitation Policy and flowchart. The Resus procedure is featured in the hospital induction. All clinical staff must have basic life support training and nominated staff from services who provide staff for the Hospital Resuscitation Teams must have intermediate life support training. Training can be accessed by contacting WCH Management. Resus and Medical Emergency teams can be accessed by dialling 2222. All staff should familiarise themselves with the WCH Resus policy and equipment.

8.3 Health & Safety / Risk Management

It is the responsibility of the service provider to comply with their own organisations Health & Safety policy; however service providers are responsible for risk assessments in their clinical areas and must share any risks or concerns with WCH Management. All staff working in WCH have a duty of care not only to their patients but to themselves, their colleagues and any visitors to WCH. Staff should be advised on relevant Health & Safety (H&S) matters appropriate to their service or service provider by their Head of Department prior to beginning work at WCH and if any Health and safety issues arise during the period of their employment. All services within WCH regardless of what organisation they are from are responsible for ensuring that risk assessments for the work processes undertaken in their areas. Health and Safety is covered during the Hospital Induction. There are regular Health and Safety meetings which all service leads are invited to attend, in addition Health and Safety is a standing agenda item at the monthly Heads of Department meetings.

8.4 Infection Prevention and Control

Service providers are responsible for following their own Infection Prevention and Control policy which must meet minimum national standards and include audits around hand hygiene, waste disposal, sharps, Aseptic Non-Touch Technique (Antt) training and catheter care. Each organisation is responsible for providing staff training, including infection control and hand washing. To support staff training WCH has an ultra-violet light box that is available for all service or service providers to use as part of on-going staff training on-site. There is alcohol gel, liquid soap and hand cream readily available within all clinical rooms. Alcohol gel dispensers are located throughout the hospital for patient and public use. In addition WCH Management includes infection prevention and control/hand washing in the monthly WCH Induction programme that all new permanent staff attend. WCH Management include infection prevention and control issues as a standing item on the monthly Heads of Department meetings. Additionally issues can be raised at the bimonthly Health and Safety meetings. WCH has an SLA with Infection Prevention and Control at UHSM which links into the Infection Control team within NHSM. Hospital Management meet on a quarterly basis as the WCH Infection Control Sub Group to discuss infection control issues in WCH. 10
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Clinical staff are responsible for cleaving rooms and equipment in a clean and tidy condition for the next user. Cleaning the medical equipment they have used and for reporting any problems or failures with medical equipment, reporting this to the Medical Engineering department, Duty Manager or via the Datix incident reporting system. Staff are responsible for cleaning up after themselves, cleaning any equipment they have used and to report to the Duty Manager any instances of unclean rooms or equipment. WCH conduct monthly cleaning audits and where applicable the results are shared with services and discussed at the monthly Heads of Department meetings. If you have any questions or problems regarding Infection Prevention and Control please contact a member of the Hospital Management Team.

8.5 Smoking
Withington Community Hospital is a smoke free environment. Staff are not permitted to smoke in the grounds or on the car-park.

8.6 Treatment Centre Policies & Procedures

There are a number of Treatment Centre specific policies and procedures which are listed below, copies of these can also be found on the WCH internet and intranet pages. Decontamination of Flexible Endoscopes DSSA Formalin Spillage Protocol Latex Policy Management of Patients with MRSA Safe Use of Medical Lasers Swab, Needle and Instrument Count Policy

Section 9 Equipment & Medical Devices

WCH are responsible for the provision, product liability, repairs, maintenance and replacement of all standard medical equipment. All medical equipment is managed and maintained by the medical engineering department based at WCH. Service providers are required to ensure that all staff have completed appropriate training in the use of medical devices within their service. Service providers are liable for harm caused by the misuse of equipment or harm caused by inadequate training. Service providers must not bring new equipment onto the site without agreement by WCH Management. Items on trial at WCH must be referred to Medical Engineering and the appropriate indemnity documentation must be in place before use. Service providers are required to inform Medical Engineering immediately if there are any faults or problems with equipment. Service providers must ensure that regular cleaning of equipment is undertaken in line with manufacturers guidelines and within the standards outlined in the document available on the WCH internet and intranet pages Clinical Staff Cleaning Duties. Service providers must ensure that all equipment requiring repair, in-house or off-site, is decontaminated appropriately and that a decontamination report form is completed and sent with the equipment. 11
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Service providers must not remove equipment from the site without the permission of Hospital Management. Service providers are responsible for checking equipment prior to use to ensure it is fit for use and in good repair.

Section 10 Governance
Clinical Governance is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which clinical excellence will flourish. The management, standard of care and service quality at WCH is the responsibility of the service provider. The service provider must ensure their service meets national standards and works within national guidelines. Service providers are required to comply with the requirements of this manual including compliance to policies and procedures in Section 8. Service providers are required to communicate clearly and effectively, respecting the privacy and dignity of patients and comply fully with the Caldicott Principles and the Data Protection Act.

10.1 Complaints
WCH Management must be notified of all complaints be they verbal or written, formal or informal. A verbal complaint form must be completed and submitted to WCH Management for escalation. Any written complaints received by services must be copied to the WCH Management team. All written complaints, irrespective of which organisation is involved, are co-ordinated through the NHS Manchester Complaints Manager. See the NHS Manchester Complaints policy for further information. Information leaflets including contact details for the Complaints Manager and the PALS Service are available. Patients/visitors who wish to complain formally should be asked to put the complaint in writing. Every effort should be made to deal with verbal complaints immediately. We encourage services to deal with verbal complaints themselves though it may be necessary on occasion to contact the Duty Manager to assist.

10.2 Incident Reporting

Staff are required to report any incidents via the Datix incident reporting system which is available via a link on the WCH Intranet and investigate or co-operate with investigation appropriately and in a timely manner. Datix incident forms, irrespective of the Provider Trust, must be completed. Hard copies must be forwarded to WCH Management on the day the incident occurs. Service providers are responsible for logging incidents onto the Datix incident reporting system and for investigating incidents within their service reporting the results of any investigation to WCH Management. Please see the NHS Manchester incident reporting policy for further information.

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10.3 Record keeping

All services must adhere to their own record keeping policy.

Section 11 Safeguarding
The Safeguarding of Children is everybodys responsibility and NHS Manchester work alongside the local authority and other agencies in providing services to safeguard children in our City. All staff should know who to raise concerns with related to child protection issues in your organisation. Staff should be trained in Safeguarding Children and know the names of Child Protection professionals in their organisation.

Section 12 Patient Information

There is a leaflet entitled Withington Community Hospital: Information for Patients which must be sent out with each new appointment letter, supplies of these leaflets can be obtained from WCH Management. All information sent to or given to patients should be of a high standard and approved by the service provider or NHS Manchester.

Section 13 Clinical Cleaning Schedules

Service providers are required to undertake cleaning of clinical equipment, cleaning schedules are available on the WCH webpage.

Section 14 Contacts
An up-to-date version of the WCH telephone directory can be found on the WCH Intranet. The main Withington Community Hospital number is: 0161 434 5555

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WCH Operating Manual version 2.6 August 2010