Standard Operating Procedure for the induction of Agency ......SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 4 of 47 1 INTRODUCTION 1.1 they provide

SOP For Induction Of Agency Registered Nurses And Midwives V1 2020 02.Docx Page 1 of 47

Standard Operating Procedure for the induction of Agency Registered Nurses and Midwives

Primary Intranet Location

Version Number

Next Review Year Next Review

Month

Nursing and Midwifery 1 2020 February

Current Author

Adrian Debney and Amanda Small

Author’s Job Title

Corporate Practice Development Nurse and Head of Education and

Development

Department

Corporate Nursing – Trust wide

Ratified by

Nursing and Midwifery Policy and Standards Committee

Date

28th February 2019

Owner

Emma Hardwick

Owner’s Job Title

Chief Nurse

It is the responsibility of the staff member accessing this document to ensure that they are always

reading the most up to date version - This will always be the version on the intranet


Related Policies

Procedure for the recognition of previously acquired enhanced

Nursing, Midwifery and Operating Department practitioner skills

Associated Documents

Agency Orientation and skills passport document

Stakeholders

Agency nurses

Agency Midwives

Registered Nurses

Resourcing department

Practice Development team

Senior Nursing and Midwifery leadership team

Version Date Author Author’s Job Title Changes

V1

February

2019

Adrian

Debney

and

Amanda

Small

Corporate Practice

Development Nurse

and Head of

Education and

Development

New Procedure


CONTENTS

Ref No

SECTION TITLE Page No

1 INTRODUCTION 4

2 PURPOSE AND SCOPE 4

3 DEFINITIONS 4

4. RESPONSIBILITIES 5

4.1 External employing agencies 5

4.2 Trust Central Resourcing Department 5

4.3 Department Managers/Nurse or Midwife in charge 6

4.4 Agency Workers 6

4.5 Practice Development Team 7

5 PROCEDURE 7

6 REFERENCES 10

7 APPENDICES 10

Appendix 1: Booking form for agency workers 11

Appendix 2: Agency worker orientation booklet and skills

passport

13

Appendix 3: Process for agency worker employment, induction

and competency assessment.

46


1 INTRODUCTION

1.1

The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust is committed to ensuring

the highest standards of patient care and safety at all times by ensuring that the services

they provide to their patients have appropriate governance assurances in place.

1.2 It is recognised that, in order to ensure the provision of services, agency workers may have

to be appointed to cover variable periods of time. Such cover may be necessary as a result

of staff shortages through absence or vacancies.

1.3 The Trust is committed to ensuring that all agency workers will:

receive an appropriate induction to the area in which they will provide work.

be aware of and work in accordance with trust policies and procedures.

have achieved the necessary standards of competence to practice enhanced clinical

skills.

have access to the necessary resources such as Information technology to be able to

effectively undertake their role.

2 PURPOSE AND SCOPE

2.1

The purpose of this document is to ensure that all key stakeholders including managers and

agency workers are aware of their responsibilities with regard to the induction and

competency assessment of agency workers.

2.2 The standard operating procedure (SOP) will ensure a consistent process is in place for

inducting agency workers into the trust and to ensure compliance with the Trusts policies

and procedures.

2.3 This procedure may also be used to provide guidance to additional training or practice and

educational interventions where practitioners have an identified skills, knowledge or

practice need.

2.4 This SOP applies to all agency workers employed through an external agency, it does not

apply to staff employed on the trust bank as these employees will receive their induction

via the Trust’s corporate induction process.

3 DEFINITIONS

3.1

Agency worker

A person from an external source providing the Trust with necessary skills on an “as and

when required” basis.

3.2 Competence

The NMC uses competence to describe skills and the ability to practise safely and effectively

without the need for supervision (NMC, 2018). Competence is contingent upon assessment

of specific knowledge and skills to ensure that practitioners are compliant with stated

standards of practice.

3.3 Assessment

Assessment is variably defined as ‘a means of collecting data to demonstrate that an

acceptable standard of practice has been reached and upon which a decision to declare a

practitioner competent can be made’. (Hand, 2006). Assessment may be reached using a

range of methods which are aligned with the stated learning outcome. This may include

reflection, rated observation, critical analysis, summative testing and peer review.


4 RESPONSIBILITIES

4.1

External employing agencies

External agencies are responsible for providing:

personal details and Curriculum Vitae (CV) for individual agency workers.

evidence of current professional registration including any restrictions placed upon

the agency workers practice and skills competencies for individual agency workers.

evidence that all pre-employment checks have been undertaken for individual

agency workers including DBS check and occupational health clearance.

evidence that the agency workers mandatory training compliance is up to date for

the following mandatory subjects:

- conflict resolution.

- Equality and diversity.

- fire safety awareness

- health and safety awareness.

- infection prevention and control.

- information governance.

- manual handling.

- Basic Life Support and anaphylaxis.

- safeguarding adults level 2.

- safeguarding children level 3 (as required).

evidence that the agency worker has undertaken the following training:

- Mental capacity act 2007

- NEWS2

agency workers will have access to trust information via The Queen Elizabeth

Hopsital Kings Lynn NHS Foundation Trust Agency workers website

https://qehklagency.wordpress.com/

4.2 Trust Central Resourcing Services (CRS) department

The Central Resourcing Services (CRS) department is responsible for checking and recording

the following information on the booking process for agency workers checklist (Appendix

1).

screening agency workers CV to ensure suitability to work.

forwarding the CV of suitable agency workers to the Deputy Chief Nurse or

Associate Chief Nurse for approval.

informing the agency of the decision to approve or decline the agency worker.

recording the agency workers professional registration details.

checking the personal identification of the agency worker

notifying the Trust’s Security office to provide ID badge

sending notification of new starter form to IT service desk to request IT user name

and password for the agency worker.

The CRS department is also responsible for:

maintaining records of the booking process.

providing the agency worker with a copy of the trust orientation and skills passport

booklet (Appendix 2).

maintaining records of completion of the local induction checklist for agency

staff (Within the skills passport Appendix 2).

4.3 Department managers/Nurse or Midwife in charge

All ward managers or the Nurse/Midwife in charge is responsible for:

checking workers are carrying accurate ID for the Trust and their agency and are

complying with trust uniform policy.

completing part one of the agency local induction checklist within the individual

agency workers skills passport (Appendix 2) in every new clinical area the agency

worker is rostered to.

completing part two of the induction checklist within 2 hours of the agency workers



first shift in the trust.

ensuring the agency workers is assessed undertaking drug administration.

returning the agency local induction checklist to the CRS department.

ensuring that the Clinical skills Declaration assessment form (Within the skills

passport Appendix 2) is completed for pre-existing skills appropriate to the clinical

area that the agency worker has evidence of competency for and send a copy of the

completed form to the CRS department.

4.4 Agency workers:

All agency workers are responsible for ensuring:

that their conditions for practice are maintained and recorded with the Nursing and

Midwifery Council (NMC) through revalidation to ensure entry onto the professional

register.

identifying practice requirements and any educational, development or training

needs which may be needed to meet these requirements to the requisite standard.

accessing and engaging with information, expectations and orientation

requirements of the Queen Elizabeth Kings Lynn Hospital NHS Foundation Trust

provided via the Agency Nurse Website (https://qehklagency.wordpress.com/) and

agency worker orientation booklet (Appendix 2).

completion of assessments as detailed on the welcome page of the agency website

prior to commencing in trust.

that they arrive on time and report to the operations centre to sign in before being

deployed to the clinical area that they are booked to work.

they collect their IT user name and temporary password from the operations centre

and undertake online IT training.

they perform their assigned tasks and responsibilities to the standards of

performance required including adherence to the Trust’s core values and policies

and procedures.

that they wear the agency uniform that they are representing and have their name

badge present at all times.

seeking clarification if they are unclear of any duties assigned to them

they work within their professional guidelines and within their scope of practice

(NMC 2018).

escalating any concerns to the nurse/midwife in charge.

accepting redeployment to other clinical areas according to patient acuity and

dependency unless they have a justifiable reason.

that they take their allotted breaks throughout their shift (1 hour total break time

during a long day and 30 minutes in an 8 hour shift).

4.5 Practice Development Team

The practice development team are responsible for ensuring that all information contained

within the dedicated trust agency website is current and updated as required. The practice

development team can also be contacted to provide training, support and competency

assessment of individual agency workers.

5 PROCEDURE (illustrated in Appendix 3)

5.1 The employing agency will undertake appropriate pre-employment and professional

registration checks for individual agency workers. This will include a robust framework for

declaration and recording of current competency status.

5.2 The employing agency will send each individual agency workers CV, evidence of pre-

employment checks and competency checklist to the trust CRS department for

consideration of employment.



5.3 The CRS department screens the individual agency workers information to ascertain

suitability for employment within the trust and collates details of the agency worker using

the agency booking process checklist (Appendix 1). If any agency workers are deemed

unsuitable at this point, the agency is contacted to inform them that the agency worker has

been declined employment and the reason for this.

5.4 Suitable Agency worker details are forwarded to the Deputy Chief Nurse (DCN) or Associate

Chief Nurse (ACN) for consideration. These details are reviewed and a decision made to the

suitability of the agency worker for employment within the trust. This decision is

communicated to the CRS department.

5.5 The CRS department will inform the agency of the decision to approve or decline the

agency worker employment within the trust. The CRS department will send a new starter

form to the IT service desk to request an IT user name and password be set up for the

agency worker. These temporary log in details will be provided in a sealed envelope for

the agency worker to collect from the operations centre on their first shift.

5.6 Following confirmation of employment, the agency will provide the agency worker with

the website address for the Trust agency worker website

https://qehklagency.wordpress.com/ . The agency will inform the agency worker that they

must access the website prior to their first shift with the Trust. The Agency worker can

download and complete the drug administration competency assessment and access other

competency assessment documents listed in their induction checklist however copies of

these are contained within the skills passport (Appendix 2) which will be provided to them

on their first shift within the trust.

5.7 On arrival for their first shift, the agency worker will report to the operations centre to:

Sign in and confirm ward allocation with the site manager.

Collect their induction booklet and skills passport.

Collect their temporary IT log in details.

The agency worker should then report to their allocated ward or clinical area.

5.8 Within the first hour of the agency workers first shift within a new clinical area, the

nurse/midwife in charge must orientate the agency worker to the clinical environment and

complete with the agency worker, the first section of the induction checklist (within the

skills passport Appendix 2).

5.9 Within the first 2 Hours of the agency workers first shift, part 2 of the induction checklist

should be completed. This section relates to a more in depth orientation to the clinical

area, medicines management and documentation. The nurse/midwife in charge may

delegate this to another member of the team to complete or the Practice Development

team can be contacted to support this process.

5.10 Agency workers must be assessed undertaking administration of medicines/a drug round

during their first shift by a registered professional who is competent in administering

medications. The drug round assessment form should be completed (contained within the

skills passport), a copy should be sent to the CRS department and competence must be

recorded on part 2 of the induction checklist. The Practice Development team can be

contacted to support this process.

5.11 On completion of part 1 and 2 of the induction checklist, the nurse/midwife in charge must

take a copy of the completed checklist and send to the CRS department for central record

keeping. The agency worker should keep the original document within their skills passport

for future assurance for other clinical areas.

5.12 For subsequent shifts the agency worker should be asked for their skills passport for

evidence of competence and completion of orientation. When working in a new clinical



area, the nurse/midwife in charge must orientate the agency worker to the ward layout

and complete section 1 of the induction checklist. There is no requirement to repeat

completion of section 2 if the agency worker has evidence of completion within their skills

passport. If the agency worker is not able to provide this evidence then this section must

be completed again.

5.13 During the agency workers first two shifts, the agency worker must complete the Clinical

skills Declaration assessment form (contained within the skills passport Appendix 2) in order

to maintain and use the clinical skills that the agency worker has already been deemed to

be competent with and has been practicing regularly. In order to be deemed competent to

undertake the skill within the trust, the agency worker must:

Provide evidence of previously being assessed as competent, such as a completed

competency assessment package.

Read the trusts policy related to the clinical skill.

Have undertaken the skill in practice within the last 12 months.

Been observed and deemed competent by a trust substantive registered practitioner

who is competent in the identified clinical skill (The Practice Development team are

available to support in the assessment of competence if required).

The registered professional observing the skill being delivered must:

ask the agency worker for evidence of competence, such as a completed

competency package.

observe the skill being undertaken and be assured that the agency worker is

undertaking the skill safely and in accordance with trust policy.

sign the clinical skills declaration form to confirm that the agency worker is

competent to undertake the task.

If the registered practitioner is not assured that the agency worker is able to undertake the

clinical skill to the required level then they must not sign the clinical skills declaration form.

5.14 On form completion, the agency worker must send a copy of the form to the CRS

department who will update the agency workers file. The agency worker should also keep

the original within their skills passport which should be kept with them at all times when

working in the trust and should be available for inspection should this be required.

5.15 The agency worker will need to log into a PC with the temporary details provided to them

in the operations centre. Once logged in, the agency worker will be asked to change their

password. This access will enable the agency worker to access the trust intranet to access

policies and procedures, report incidents, book a porter etc.

5.16 The agency worker is expected to use the trust electronic platforms for patient care whilst

working clinically. In order to be able to access and use the trust E-Discharge and Web-ICE

blood results system, the agency worker will need to undertake the online training which

can be accessed via the trust intranet page or via the following link http://qehkl-

inet/his2/WebICE_eLearn.aspx If the agency worker has trouble with accessing the system,

please contact the IT service desk on extension 4422 who will be able to provide guidance.

5.17 The agency worker is expected to be able to monitor blood glucose levels whilst working in

the trust, using the Nova StatStrip Glucometer. Training is available throughout the day on

the Friday of trust induction however should agency workers not be working on this date,

there are a number of train the trainers who can deliver this training on a one to one basis.

Ward managers must ensure that the agency worker has access to this training by

contacting the divisional train the trainer.

5.18 The agency worker is expected to undertake the blood transfusion e-learning modules via

the LearnPro system prior to their first shift to ensure that blood transfusions are

administered in line with national guidance. This e-learning should be accessed via

http://qehkl-inet/his2/WebICE_eLearn.aspxhttp://qehkl-inet/his2/WebICE_eLearn.aspx


http://nhs.learnprouk.com

5.19 The CRS department will keep records of all training and induction checklist compliance

within the agency workers personal file.

5.20 Adherence to this SOP will be monitored via quarterly audits of completion rates of the

agency induction checklist.

6 REFERENCES

6.1 Hand H (2006) Assessment of learning in clinical practice, Nursing Standard, 21, 4, 48-56

Nursing and Midwifery Council (NMC) (2018) The Code: Professional standards of practice

and behaviour for nurses, midwives and nursing associates

7 APPENDICES

Appendix 1: Booking form for agency workers

Appendix 2: Agency worker orientation booklet and skills passport

Appendix 3: Process for agency worker employment, induction and competency assessment.

http://nhs.learnprouk.com/


Appendix 1: Booking form for agency workers


Name…………………………………….

Welcome Guide for Agency Nurses Working at

The Queen Elizabeth Hospital Kings Lynn

NHS Foundation Trust

Skills Passport and Orientation Information

Appendix 2: Agency worker orientation booklet and skills passport


Dear Agency Nurse,

On behalf of Team QEH, I would like to welcome you to the Queen Elizabeth Hospitals NHS Foundation

Trust Kings Lynn. This document will outline the standards, requirements and expectations of you as an

Agency Nurse working as part of our team and will outline the support you will receive whilst working with

us.

We want all of our patients to experience care in our hospital that is safe and effective and delivered at all

times with care and compassion. Our Values are integral to this and our expectation is that all staff

including agency workers will observe these as a consistent underpinning for their conduct, attitude,

practice and aspirations.

Agency Nurses are an essential part of our Nursing workforce, whilst working at the hospital you can

expect to be treated with the same high standards of professional respect which are accorded to all staff

regardless of position or role.

We recognise that you bring with you a wealth of experience and skills gained from working in a wide range

of organisations and specialities. You will also have completed some core mandatory training requirements

with your Agency. Therefore, this document outlines the standards agreed to ensure that your skills can be

used appropriately and safely to the benefit of our patients.

I hope you enjoy working with us.

Yours Sincerely,

Emma Hardwick

Chief Nurse


Telephones and the Bleep System

It is everyone’s responsibility to answer the telephone. Please do not let a call go unanswered.

Whenever you answer the telephone remember that you are the first point of contact for the person calling.

Please state:

• Ward/Department

• Your name and position

The internal bleep system can be used to contact medical staff, senior nurses, specialist nurses/AHPs and

operational staff. Bleep numbers can also be found by looking on the intranet home page by clicking the

telephone icon.

You can check any departmental or personnel number in the hospital by simply typing the name or title into

the QEH directory which can be found on the Trust intranet page. Simply click on ‘phone book’ from the

menu on the left and the directory search engine will be displayed as shown.

.

Emergencies Dial 2222 and state the emergency and location i.e. ‘cardiac arrest, West Raynham ward’.

Bleeps

1) Dial 10 (you’ll hear ‘welcome to the multi-tone paging system’

automated message)

2) Dial the desired bleep number

3) Dial your extension

4) Replace the receiver

It may be that you cannot find the correct title or name for the department which you are searching for, in which case you can

dial 0 for Trust switchboard assistance.


Admissions Main Desk 4010 ITU 3570

Castle Acre Ward nurse station 3710 Leverington Ward -SAU Nurse station

4110

A&E Reception front desk 4090 Main Theatres Reception 3740

A&E Paed Nurse station 3560 Marham Ward 4280

A&E Resus. 1 4420 Necton Ward Nurse station 4170

A&E Resus 4 4410 Gayton Ward Trauma Room 3280

A&E Resus. 4 4400 Oxborough Ward Nurse station 4380

Delivery Suite Nurse station 3720 Windsor Ward 4180

Elm Ward 4260 Physiotherapy 4240

Feltwell Ward 4370 Porters 2441

Gayton Ward Nurse station 4160 NICU Nurse station 3730

Discharge Lounge 3640 Stanhoe Ward Nurse station 3121

Endoscopy Recovery Nurse station 3760 Terrington Ward (Assessment Zone) Main desk

4310

Pathology 'Bacteriology con's office' 4360 Ops Centre 3058

Pharmacy (mobile phone) 3750 Tilney Ward 2547

Physiotherapy 4240 AEC 2923

Porters 2441 Occupational Health 3757

Rudham Ward Nurse station 4120 Switchboard 0

Blood transfusion lab 3782 Haemochemistry lab 2796

Some Useful Numbers….


An IT user name and password has been created for you by the IT service desk. Your log in details will be

held in a personalised envelope for you within the ‘operations centre’ for you to collect when you sign in to

work.

The ICT Service Desk is available for support during the following hours:

Monday to Thursday: 07:30-17:30

Friday: 07:30-17:00

They can be contacted on extension 4422 (01553 214422) or via email [email protected]

Logging into the PC for the First Time

Once you have collected your user name and password from the ‘operations centre’, you can log into a PC.

You will be prompted to change your password immediately:

Once logged in, you will be prompted to set three security questions via Passworks, which you can use to

reset a forgotten password in the future.

Locked Computer/Passworks Functionality

On the log in screen, click on the ‘Click here to reset your password or unlock your account’ link

on the blue banner.

Type in your Windows Username, then click ‘Next’. Answer the questions, then either Unlock, or reset your

password as appropriate.

In order to use our E-Discharge system, you will need to undertake the E-Discharge online training which

can be accessed via the trust intranet page. Go to Web-Ice/ICE on line training tab for more information.

IT Access and Induction

mailto:[email protected]


In order to be issued with a bar code to be able to administer blood transfusions, you are required to

undertake the blood transfusion e-learning modules via the LearnPro system. This e-learning package

should be undertaken prior to your first shift at The Queen Elizabeth Hospital Kings Lynn.

You can access learnPro NHS via http://nhs.learnprouk.com

Blood transfusion module

After you have registered with LearnPro NHS, please complete the blood transfusion e-learning module by

accessing https://www.learnbloodtransfusion.org.uk/ .

LearnPro – Blood transfusion e-learning

Registering with LearnPro NHS In order to undertake the e-learning module you must register with LearnPro NHS. On the login page, below where it asks for your login details, you will see a link to create an account. Please complete the registration form, selecting your location (Queen Elizabeth Hospital Kings Lynn) and Job role. An account will then be created for you.

Policies and Guidelines

You will need to log into LearnPro NHS using the login details provided to you when you completed the registration process. Please click on the bottom right hand corner of the webpage to go to the log in screen.

http://nhs.learnprouk.com/https://www.learnbloodtransfusion.org.uk/


Trust policies, procedures, protocols and guidelines underscore all practices for staff working here. These

are to support and guide you and to ensure that patient care is safe and consistent. You can access these

via our dedicated agency website via the following link: https://qehklagency.wordpress.com/ or via the

QEHKL trust intranet site.

The nurse in charge will help you to

identify policies which are specific to

specialist areas such as respiratory

medicine, stroke or surgical assessment

but you should also access pages on the

QEH intranet (see diagram on right) for

policies and guidelines for your general

reference. Nursing and Midwifery

documents are accessed via the Nursing

and Midwifery sub site.

You should begin by familiarising

yourself with the essential policies

below.

Procedure for the

recognition of previously

acquired enhanced Nursing,

Midwifery and Operating

Department Practitioner

skills

Control of medicines policy

Delegation by registered

practitioners to support

workers accountability

policy

Procedure for the

preparation and

administration of IV

medications

Practising Clinical Skills at the Queen Elizabeth Hospital Kings Lynn, NHS Foundation Trust

Dress code policy

Safeguarding vulnerable

adults

Student scope of practice



We wish to support you as a Registered Nurse to use and maintain the clinical skills you have already been

deemed to be competent with and have been practicing regularly in line with the trust procedure for the

recognition of previously acquired enhanced Nursing, Midwifery and Operating Department Practitioner

skills. These skills will include:

• Peripheral Intravenous Drug Administration

• Peripheral Cannulation

• Peripheral Venepuncture (routine bloods, but NOT blood cultures)

• ECG recording

As a Registered nurse/midwife and in line with the NMC code (2018) you are professionally accountable for

undertaking skills and tasks for which you are competent. If you are asked to do anything that is outside of

your scope of practice please report this to the Nurse in Charge or the Site Practitioner team and refer to

the relevant guideline or policy for details.

In order to undertake any enhanced Nursing skills, you will need to demonstrate the following:

Evidence of previous competency such as a completed competency assessment form.

Evidence of knowledge of the relevant QEH policy or procedure.

Demonstrate competence in line with the relevant QEH competency assessment document.

You may practice the skill under direct supervision of a competent practitioner prior to being formally

assessed if required. It is your responsibility to read and understand the policy and procedures related to

any pre-existing enhanced clinical skills you may have. The manager (or delegated assessor of clinical

competence) must be assured that you have sufficient knowledge of the relevant QEH policy or procedure

prior to deeming you competent to undertake that skill.

Demonstration of achieving all of the above must be noted on the ‘Clinical Skills declaration form’ which

can be found at the back of this skills passport.


The Queen Elizabeth Hospital Kings Lynn utilises the adult sepsis screening tool below to aid the

identification of sepsis and to ensure timely escalation to the Critical Care Outreach team or medical team.

Please familiar yourself with this screening tool before your first shift.

Adult Sepsis Screening Tool

Sepsis 6 Care bundle


The sepsis 6 care bundle must be used for any patients that have sepsis. Please familiarise yourself with

the sepsis 6 care bundle below before commencing your first shift.


Uniform

We expect all candidates to have a clean and ironed uniform whilst on duty within The Queen Elizabeth

Hospital Kings Lynn NHS foundation trust, this is to ensure that agency staff are upholding the same

standards as substantive staff.

The Trust won’t allow candidates to have plain scrubs/tunics on whilst working, they need to wear the

agency uniform they are representing and also have their name badge present to ensure they can be

identified correctly.

Moving Wards

The Trust expect all Nursing staff including agency Nurses to be flexible whilst on duty and if required may

ask a nurse to move departments during their shift. This is to ensure that staffing levels throughout the

wards are balanced and that patient safety is kept to high standards.

If Nurses are found to challenge the ward or refuse to move whilst on duty they may face being restricted

from the Trust. If there are extreme circumstances as to why a candidate cannot work on a ward, this

needs to be stated in advance to be reviewed by the Trust leadership team.

If you do move to a different ward, please get a timesheet signed to reflect the hours spent in each

department, this may mean that you need to bring extra timesheets to work.

Signing in

All candidates need to report to the Ops centre prior to their shift starting to sign into the attendance book,

the reason for this is to ensure the candidates are accounted for and to ensure they attend the correct

department. When you sign in for your first shift, please also collect the envelope containing your IT user

name and password.

Break Policy

All Nurses working a long day within the Trust will be given 1 hour break and Nurses working an 8 hour

shift will be given a 30 minute break. You must take your allotted breaks throughout your shift as you will

not be paid if you work through your break unless the timesheet is countersigned by the Nurse in

charge/ward manager to confirm this was agreed.

Our expectations of you


Name…………………………………….

Induction Checklist and Skills Passport for Agency Nurses working at

The Queen Elizabeth Hospital Kings Lynn

NHS Foundation Trust


Prior to commencing in the trust, please ensure that you have completed the following core mandatory

training with your Agency and record evidence of this below.

Training Required: Date Obtained Conflict Resolution Equality & Diversity Fire Awareness Health & Safety Infection Prevention and Control Information Governance Manual Handling Basic Life Support Safeguarding Adults Safeguarding Children Level 2/3 – as appropriate

Mental Capacity Act 2007 NEWS2 Training

You will also have received enhanced DBS clearance – please complete details below Enhanced DBS clearance number

Date DBS clearance obtained

Type of DBS Barring Check undertaken

Induction to Ward/Area Checklist to be Completed by Ward Staff

Mandatory Training Compliance


PART 1 to be completed within 1 hour by Nurse in charge Confirm name of Nurse and photo ID Discuss expected duties Check adherence to uniform policy Give patient handover and identify bays working in Introduction to the ward speciality Hand washing and PPE expectations Confirm sickness reporting process IG & confidentiality standards Confirm clinical skills assessment Introduce to ward team Confirm process for escalating concerns Identify coat & bag storage and discuss valuables

Ensure Nurse has collected IT login details from the operations centre

Discuss breaks & timekeeping

PART 2 to be completed in 2 hours by ward staff

Around the ward Infection control and waste Location of patient information

Screening and isolation procedures

Dietary supplements and patient food

Stool charting

Beds & mattresses

Waste management

Confirm cardiac arrest process

Storage and disposal of linen

Incident reporting process

Medicines

Ward rounds, MDT meetings and safety huddles

Location and code for the medicines room

Friends and family form – document location and procedure

Describe CD requirements – policy on website or intranet (https://wordpress.com/view/qehklagency.wordpress.com)

Medical Equipment Briefing: Practice and policy for medicines keys Tympanic thermometer Bedside medicines cupboards and code/Self

administration policy

Vital signs monitor Patient Care and related documents Emergency call bell system Risk assessments

Resuscitation trolley & contents Care rounds

Portable oxygen & suction equipment including cylinder safety

Admission MDT document

Pulse oximeter NEWS2 & deteriorating patient standards

Glucometer and how to obtain training Blood transfusion management including completion of e-learning via http://nhs.learnprouk.com

Nebulizer Mental capacity and DOLs standards

12 lead ECG Raising concerns

Piped O2 & suction (where applicable) End of life care

Assessments process and policy for discharging patients safely

Administration of medicines / drug round (Appendix a)

Fluid balance charts

Hand Hygiene assessment (Appendix b)

Agency Nurse: Confirmation of Induction to the Ward/Department

https://wordpress.com/view/qehklagency.wordpress.comhttps://wordpress.com/view/qehklagency.wordpress.comhttp://nhs.learnprouk.com/


Name………………………………………….….Signature………………………. Agency……………………………………………Date……………………………. Ward staff Name……………………….Signature………………….Designation………………. Date……………….

Professional Declaration

I………………………………………………………………………….NAME IN CAPITALS Declare that I have completed the core mandatory training requirements and undertaken relevant training and/or assessment in the skills that I undertake. I have received a local induction to the clinical area (above) and will comply with all NMC and Trust standards relating to the nursing care that I deliver. I understand that I am personally and professionally accountable for my actions whilst working as a Registered Nurse at the Queen Elizabeth Hospital Kings Lynn NHS foundation trust. NAME OF YOUR AGENCY……………………………………………………………………… Date of first shift at the QEHKL…………………………………………………………………… Signature…………………………………………………Date…………………………………..

Original copy to be retained by Agency Nurse/Midwife.

1 copy to be sent to the Central Resourcing Department, Inspire Centre.


In order to use and maintain the clinical skills you have already been deemed to be competent with and have been practicing regularly, you will need to be observed for each skill to demonstrate safe practice in accordance with Trust policies. Additionally, you will need to have your declaration form signed by a Trust Registered Nurse who is competent in that procedure. Please amend the form on the following page by striking through those items which are not applicable to you. Please keep your signed declaration form on you at all times while you are working in clinical areas at the QEH and be prepared to produce it if asked by a member of Trust staff. Please send a copy of the signed declaration form to the Central Resourcing Department to enable our records to be updated accordingly.

Clinical Skills Declaration form


Clinical Skills Declaration Form

Surname Forename

Correspondence Address

Home Email

Telephone

Mobile

NMC PIN and expiry date

Agency Nurse Trust Registered Practitioner IV Administration of Medications (Please tick and initial the relevant boxes below)

I have observed the above named person and assessed them as safe to practice Peripheral Intravenous Administration of Medications including: Adherence to ANTT at all times Correct drug calculation Knowledge of medication being administered and potential complications Knowledge of anaphylaxis The individual has provided evidence that they have been trained in this skill to the same standards as the QEH competency assessment

I have read the QEH procedure for the preparation and administration of intravenous medications for adult patients

I have been assessed as competent in this skill

Signature……………………… Print……………………………… Designation……………………. Ward/Dept……………………….

I have undertaken this skill in clinical practice within the last 12 months

Peripheral Intravenous cannulation (Please tick and initial the relevant boxes below)

I have observed the above named person and assessed them as safe to practice Peripheral Intravenous Cannulation including: Adherence to ANTT Knowledge of basic anatomy/physiology of upper limb Adherence to IP&C measures Safe use of sharps as per HSE 2013 regulations The individual has provided evidence that they have been trained in this skill to the same standards as the QEH competency assessment

I have read the QEH Cannulation policy




Venepuncture (Please tick and initial the relevant boxes below

I have observed the above named person and assessed them as safe to practice Venepuncture including: Adherence to ANTT Knowledge of basic anatomy/physiology of upper limb Adherence to IP&C measures Safe use of sharps as per HSE 2013 regulations The individual has provided evidence that they have been trained in this skill to the same standards as the QEH competency assessment




ECG (Please tick and initial the relevant boxes below)

I have observed the above named person to demonstrate safe practice in recording ECG’s including: Knowledge of anatomy and conduction systems Recognising life threatening abnormalities Correct recording of ECG Correct labelling and processing of ECG post recording





Appendix A

Declaration

I, the undersigned, make a formal declaration that I have attended previous

training and have been assessed as competent in the above named clinical

skills. I acknowledge my professional accountability and agree to only act within

the limits of my knowledge and competency; maintaining my knowledge and

skills for safe and effective practice (NMC The Code 2018)

Name ……………………………………………………………………..

Your Agency……………………………………………………………..

Signature………………………………………………………………….

Date: ___ / ___ / _______

Original copy to be retained by Agency Nurse/Midwife 1 copy to be sent to the Central Resourcing Department, Inspire

Centre


Clinical Practice Assessment

Administration of Medicines by

Registered Practitioners

Author Ragna Page

Author’s Job Title Practice Development Nurse

Department Division 1

Ratifying Committee The Nursing & Midwifery Policy & Standards Committee

Ratified Date December 2018

Review Date December 2021

Owner Emma Hardwick

Owner Job Title Chief Nurse

NAME OF CANDIDATE (PLEASE PRINT)……………………………………………………………………………

NAME OF ASSESSOR/S (PLEASE PRINT)……………………………………………………………………………



DATE STUDY DAY ATTENDED (if applicable) ……………………………………………………………………

DATE OF ASSESSMENT……………………………………………………………………………………………..

SIGNATURE OF ASSESSOR…………………………………………………………………………………………..

SOP for Induction of Agency Registered Nurses and Midwives v1 2020 02.docx Page 31 of 47

INTRODUCTION

The purpose of this document is to verify that Registered Practitioners working in the Queen

Elizabeth Hospital Kings’ Lynn NHS Foundation Trust are familiar with local policies and procedures

relating to the safe administration of medications (excluding IV Medications) to patients.

This document is designed to be used in conjunction with The Queen Elizabeth Hospital King’s Lynn

NHS Foundation Trust’s “Medicines Management – Safe and effective use of medications on the

wards” booklet.

Guidance for Completion

Candidate

Please complete the sections on pages 4-7 and 15 PRIOR to your observed medications assessment.

In areas where no ‘formal’ drug rounds are conducted the section relating to that element may be

marked as Not Applicable. However, you will still be observed/assessed in terms of your practice

relating to underpinning knowledge and safe administration of medications in the setting that you

are working in.

Assessor

Assessors must be Registered Practitioners who are deemed competent in the administration of

medications and have completed their preceptorship programme.

You must assess the individual’s competency to undertake this skill independently using this

assessment document. All elements of the procedure must be assessed. An omission of any element

of the assessment must result in the individual being referred, and re assessed at a later date,

following further supervised practice.

Once this assessment is completed a copy should be placed on the personal file, and a copy retained

for the individual portfolio. Local records should be kept detailing all individuals who are

competent in this skill.

Assessors are required to test the Registered Practitioner’s knowledge of the drugs commonly used

in ward/unit/department that is the Registered Practitioner’s primary ‘base’. This should include

knowledge relating to indications, contraindications, common side effects, therapeutic dosage

range and any special measures that relate to specific medications e.g. Insulin.

Use this document to record assessment/knowledge of a minimum of 10 different drugs routinely

used in the ‘base’ ward/department, randomly selected from a range of different categories of

drugs.

Should include a minimum of 1 of each of the below:

Antibiotics

Single drug analgesics

Combined analgesic preparations

Diuretics

Inhaled medications


Aperients

Respiratory medications

Cardiac medications

Diabetes medications

Anti-emetics

(In rare occasions this will not be possible - please speak to the practice development team for

advice in these circumstances).

In order to demonstrate competence in the ability to undertake calculations relating to medications

the calculation on page 15.of this document must be correctly completed by the Registered

Practitioner.

Assessment Tool for Administration of Medicines by Registered Practitioners

Performance Criteria

Evaluation method Achieved/Referred

Date Assessor

Knowledge of Legislative Framework & Trust Policy and

Procedures

Identify 3 Acts of Parliament relating to Medications.

Written response

Achieved/Referred

The Queen Elizabeth Hospital King’s Lynn NHS Foundation

Trust’s current Control of Medicines Policy relating to:

Ordering:

Describe how medications are ordered in your work area.

Written response

Achieved/Referred

Custody

Who may have the ‘keys’ to access medications?

Who is ultimately responsible for the ‘Keys’ in each

department?

Who can ‘supervise an unlocked Drugs Trolley or

Cupboard in the event that you have to leave it urgently?

Describe the process in the event that the ‘Keys’ are lost.

Written response

Written response

Written response

Written response

Prescribing

List the minimum requirements for a prescription to be

legally valid.

Describe additional safeguards for prescribing

Methotrexate.

Describe the prescription process for drugs that are

Written response

Written response

administered less frequently than once daily.

Patient Group Directives (PGD’s) - List those in place in

our your ward/unit/Department.

Written response

Written response

Administration

List 3 medications that require a 2nd checker.

Who can act as 2nd checker for non-Chemotherapy

medications?

Describe the process for administration of Controlled

Drugs.

Describe the process to be followed in the event of a

Drug Error.

Written response

Written response

Written response

Written response

Observed Practice:

Preparation

Ensures that drug trolley/cupboard is secure and

appropriately stocked and clean.

Able to identify different medication storage locations

within the department.

Observation

Questioning/observation

Patient Safety

Carries out hand hygiene correctly.

For every Patient - correctly verifies all elements of safety

checks prior to commencing administration:

Full name

Hospital number

Date of Birth

Allergy status

Patient Weight is documented

Patient Safety

Hand hygiene between patients.

Correctly documents any drugs being omitted and

escalates appropriately.

Identifies drug errors, escalates and reports in line with

the Control of Medicines Policy.

Ensures stocks are replenished/reordered and sufficient

stock/Patient Own medications will be available for next

practitioner.

Ensures storage areas/trolleys/cupboards are clean and

secure on completion.

The practitioner has knowledge of the correct procedure

to follow in the following situations so that medication

doses are not omitted.

Missing prescriptions.

Missing patient during a medicine round.

Drug not being available.

Observation

Observation

Observation

Observation

Observation

Observation/Questioning




Communication

Seeks consent from patient

Carries out pain assessment prior to administration of

analgesics

Observation

Observation

Gives each patient suitable explanation of drugs about to

be administered

Provides adequate support/assistance and supervision for

patient to ensure patient takes medication

If patient refuses medication appropriately explores

reasons, documents accordingly and escalates if

indicated

Able to describe current assessment need/ condition for

each patient and how this relates to the indication for

each medication

Verifies validity of prescriptions

Verifies expiry dates of each medication prior to

dispensing

Ensures that any required checks relating to the patient’s

vital signs are verified/recorded e.g. BP, BM etc. prior to

administration.

Able to describe indication/contraindications/normal

dosage range/potential interactions with other

prescribed medications and common side effects of each

medication administered (May refer to BNF for

medications not routinely given in

ward/unit/department)

Signs for medications AFTER administration

Observation Observation Observation/Questioning

Observation/

Questioning

Observation

Observation


Observation

Drug Calculations/Medication Questions

Calculation/Medication Questions on PAGE 15

completed 100% accurately

Calculations as part of observed practice 100% accurate

(if applicable)

Written response

Written response/

Observation

When the assessment is complete please delete and sign as indicated. A copy of the completed document must be placed in the practitioners personnel file PASS REFER Signature of Assessor ----------------------------- Signature of Candidate --------------------------------------- Date --------------------------------

Supervised Practice Record for

Use this to record your episodes of supervised practice & reflective discussion of issues highlighted or discussed throughout the clinical supervision period.

Date Performed Comments Comments/Signature of

Assessor

Assessors - Please record the drugs you have questioned the nurse, midwife or operating department practitioner on (Minimum of 10 different

drugs)

Category Drug Category Drug

Antibiotics

Aperients

Single drug analgesics

Respiratory medications

Combined analgesics

Cardiac medications

Diuretics

Diabetes medications

Inhaled medications

Anti-emetics

Other Others

Others

Others

Calculations/Medication Questions

Please complete the following calculation prior to observed assessment process. Additional calculations may need to be

undertaken as part of supervised practice – please record these below.

Convert the following:

3500micrograms = milligrams 4.320milligrams = micrograms

2760millilitres = litres 1.430litres = millilitres

1.25grams = milligrams

Complete the following calculations

A patient requires 450mg of a drug to be given that comes in 150mg tablets how many would you give?

A patient requires 7.5mg of a drug that comes as a solution of 5mgs/10mls, how much would you give?

A patient requires 500mcg of adrenaline that comes as 1mg/1ml, how much would you give?

Your patient is prescribed 40mgs of drug A. In your trolley you have ampoules for injection of 50mgs per 2mls. What volume will you be required

to administer?

Answer the following:

How long can a bottle of Lactulose remain in the trolley once opened?

Where would you store an insulin pen once opened?

How long can an insulin pen remain in use once opened?

Comments (Assessor)

Comments (Registered Practitioner)

When the assessment is complete please delete and sign as indicated.

A copy of the completed document must be placed in the practitioner's personnel file

PASS REFER _________________________ _________________________

Signature of Assessor Signature of Candidate

Date_____________________

* Throughout this document the term “practitioner” relates to Registered Practitioners who, in line with Trust Policy, may undertake the administration

of medications to patients.

Medications Assessment

Name: ...........................................................

Date of Final Assessment: ………………………………………………………….

Assessors Name: ...........................................................

Assessors Signature: ...........................................................

Ward/Department: …………………………………………………………

Once you have successfully completed all elements of your Medications Assessment, please scan and e mail or return this sheet to:-

E.S. R, [email protected]


Appendix B

Clinical Practice

Hand Hygiene

Assessment for

Professional Staff and

Support Workers

Online QEH Phone book


Assessment tool for hand hygiene technique for professional staff and support workers*

For the purpose of this document support worker is the term to describe any individual working in a supporting role to registered staff

When the assessment is complete please delete and sign as indicated.

A copy of the completed document must be placed in the practitioner's personnel file

PASS REFER _________________________ _________________________ ________________________

Signature of Assessor Signature of Candidate Print Name

Date__________________

Performance Criteria Evaluation Method Achieved/Not Achieved Date Assessor

Demonstrate Knowledge of:

a) The role of hand-washing in minimising the risk of patients

developing health care associated infections Questioning Achieved/Not Achieved

b) The ‘ 5 moments’ for hand hygiene Questioning Achieved/Not Achieved

c) Hand decontamination

When decontamination with soap and water is required

When it is suitable to decontaminate hands with hand

sanitiser

‘Bare below the elbows’

Use of hand moisturiser

Questioning Achieved/Not Achieved

Demonstrate knowledge / clinical competence of :

d) Hand decontamination technique

Routine hand decontamination using soap and water

Hand drying

Routine hand decontamination using hand sanitiser

products

Observation Achieved/Not Achieved


Appendix 3: Process for Agency worker employment, induction and competency

assessment.

Continued on next page

Agency worker details are reviewed by DCN

or ACN. Approval or decline communicated to CRS department.

Nursing agency provides Agency worker

with link to dedicated agency induction

website

(https://qehklagency.wordpress.com/) and

records staff engagement. Agency staff

MUST download and access documents and

assessments prior to their first shift as per

the directives on the welcome page.

Pre-employment and competency checklist completed by agency, CV and employment

checklist sent to CRS department.

CRS department screens Curriculum Vitae, employment checklist and NMC status.

Approval to employ

Any Agency workers deemed

unsuitable to employ are not considered further at this point

Suitable Agency worker details forwarded

to Deputy Chief Nurse (DCN) or Associate Chief Nurse (ACN) for consideration.

CRS department informs Agency

CRS department informs Agency

of reason for decline

Unsuitable Suitable

Unsuitable

Suitable



Within first Hour: Nurse in charge arranges for a member of the nursing team to complete

the induction checklist with the agency nurse. Some parts of this may be completed by a

Health Care Assistant.

Within first 2 Hours: Part 2 of the induction checklist should be completed. The Practice

Development team can be contacted to support this process.

During first Shift: Drug Round / administration of medicines. Agency nurses assessed during

first shift administering medications on drug round to at least one bay of patients. Complete

drug round assessment form, send a copy to the resourcing Dept and record on part 2 of the

induction checklist. The Practice Development team can be contacted to support this process.

During First Two Shifts: Clinical skills Declaration assessment form completed for pre-

existing skills appropriate to clinical area that the agency nurse has evidence of competency

for as per the Pre-existing clinical skills policy. One copy of the form to be retained by the Agency Nurse and an additional copy sent to the resourcing department.

During first Shift: Agency nurse and nurse in charge complete the induction checklist (parts 1

& 2). 1 copy to be retained by the agency nurse and an additional copy sent to the

resourcing Dept.

For Subsequent shifts the agency nurse should be asked for their skills passport for evidence

of competence and completion of orientation. When working in a new clinical area, the

Nurse in charge must orientate the agency nurse to the ward layout and complete section 1

of the induction checklist.

Within first Hour: nurse in charge completes the first section of the induction checklist with the agency nurse.

On arrival for their first shift, the agency worker will report to the operations centre to:

a) Sign in and confirm ward allocation with the site manager.

b) Collect their induction booklet and skills passport.

c) Collect their temporary IT log in details. d) The agency worker should then report to their allocated ward or clinical area.