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Operating Manual
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
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
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.
3.3 Security
Withington Community Hospital has 24 hour security on site and the building and car parks are monitored by CCTV.
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.
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.
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.
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.
Clinical staff based on the 1st floor must undertake evac-chair training as the evacuation of their patients is their responsibility.
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.
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.
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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 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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