The Newcastle upon Tyne Hospitals NHS Foundation Trust. Balliol Off-Site Storage Facility Procedure for usage

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1 The Newcastle upon Tyne Hospitals NHS Foundation Trust Balliol Off-Site Storage Facility Procedure for usage Version No 2.1 Effective From 13 June 2013 Expiry date 30 June 2016 Date Ratified 12 June 2013 Ratified By Estates Senior Management Team 1 Introduction The Store will be managed by the Trust Estates & Facilities Department Estates Maintenance Manager who, by operating the facility in accordance with agreed Policy and these procedures, will provide safe, secure and accessible storage accommodation for: Records Medical, Radiology, Pharmacy, Laboratory, etc - required to be kept in storage under HSC1999/053 "For the Record". Furniture & Equipment New - awaiting placement in capital scheme developments Used - surplus to individual departments' requirements but of potential use to other departments Decanted - during other developments Electro medical equipment/surplus items awaiting collection by the Trust selected auctioneers. 2 Scope The Trust expects that all staff utilising the Balliol facility should adhere to this policy. This policy provides instructions for departments wishing to use Balliol off-site storage facility. 3 Aims The aim of this policy is to ensure controlled storage and management of the various items held in the Balliol store. 4 Duties (Roles and responsibilities) 4.1 All Trust employed staff, agency & locum staff are responsible for adhering to this policy. 4.2 The facility will be managed by the Estates Maintenance Manager. 4.3 The day to day operational issues will be undertaken by the Balliol storekeeper. Page 1 of 4

2 4.4 To comply with National/NHS guidelines on storage of medical records and confidential information, the Estates Maintenance Manager and Balliol storekeeper will take advice from the off-site storage group. 4.5 The Estates Maintenance Manager and Balliol storekeeper will be responsible for ensuring implementation of this policy. 5 Seeking Approval Departments/Specialties wishing to transfer items to the Store, should seek approval to do so by completing the Storage Application Form (available on the Trust s Intranet ) and forwarding it by to John Swinhoe, Estates Maintenance manager with a copy to Ian Martin. Where the storage requirement is for temporary decanting of items during capital scheme developments, this application will be submitted by the Estates Department or relevant Departmental Head. The application will be considered and a response notified within 14 days. Approval will not be unreasonably withheld, subject to: (i) the application form being fully completed (ii) the request being within the purpose and scope of the facility (iii) physical storage capacity being available. 6 How to Proceed Following Approval Following approval, Departments/Specialties should: 6.1 Liaise with Portering Services to seek any necessary assistance with the physical transfer of items to store. Wherever possible, Portering Services will provide both portering manpower and a driver and in such cases, hire of a vehicle (up to 3-ton with tail-lift) should be arranged by Departments/Specialties. For smaller loads, existing Trust vehicles may be available (eg Estates Dept van) and Departments/Specialties should make appropriate enquiries. Any charges levied by Portering Services should be borne by the Department/Specialty or the capital scheme. Where portering manpower and/or a driver cannot be made available or where a 3-ton vehicle with tail-lift is inadequate for the proposed transfer, then Departments/Specialties should contact John Swinhoe/Ian Martin who will assist in arranging for the work to be undertaken by a removal contractor. Again, costs must be borne by the Department/Specialty and an authorised, cost-coded non-stock requisition form will be required to confirm the booking. 6.2 Ensure that any equipment which has been in patient areas is disinfected as necessary, in accordance with the Trust Decontamination Policy. Equipment should be disinfected prior to removal from your department and also after retrieval from the facility. 6.3 Ensure that all items to be transferred are appropriately packaged and identified. Unless records are to be filed directly onto shelving by Page 2 of 4

3 Departments/Specialties, they should be boxed in storage boxes (available via NHS Logistics, see below) and each labelled, clearly showing the Department/Specialty to whom the records belong, a contact person & telephone number, a content description to aid in identification for access/retrieval, the date and a "destroy after" date (where appropriate) though responsibility for disposal will remain with the Department/Specialty. All individual items of furniture and equipment should be tagged (tags available via NHS Logistics - see below) and labelled with the same information. Banner Storage boxes, recycled board, 440x370x255mm, pack of 10, Requisition code WGC 003. Banner Manilla Tags, punched and strung, 120x60mm, pack of 10, Requisition code WZC 051. NHS Logistics tote boxes and roll cages must not be used to store or transfer goods. They are the property of NHS Logistics and are chargeable to the Trust. 3.4 Arrange access to the Store by contacting Ian Martin or Out of hours access can be gained by contacting Freeman Hospital Portering Supervisor on or Access to Stored Items Access to items in Store should be arranged as per 6.4 and retrieval of items for return to Departments/Specialties by reverse application of Annual Review It is essential that the Store does not become congested with items/records kept unnecessarily. On an annual basis, Heads of Departments/Specialty Managers will be contacted by the Supplies Department to confirm that continued storage of items in store is still required. For items no longer required, it will be incumbent upon Departments/Specialities to arrange disposal (eg by placing paper records into confidential waste sacks and arranging collection thereof or by arranging segregation and disposal of x-ray films). 9 Equality and Diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way services to the public and the way the Trust treats its staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed. Page 3 of 4

4 10 Monitoring Standard Monitoring and audit Method By Committee Frequency To ensure all records / goods / equipment deposited at Balliol Store are in compliance with policy. A record will be maintained of any records/goods/equipment deposited at Balliol Store where non-compliance with the policy [or procedure] is evident. Estates Department Off-site Medical Records Storage Group Annual 11 Consultation and review The policy will be formally reviewed every three years. Policy Author: Estates Maintenance Manager Page 4 of 4

5 THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST IMPACT ASSESSMENT SCREENING FORM A This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Policy Title: Balliol Off-Site Storage Facility Procedure for Usage Policy Author: Estates Maintenance Manager Yes/No? You must provide evidence to support your response: 1. Does the policy/guidance affect one group less or more favourably than another on the basis of the following: (* denotes protected characteristics under the Equality Act 2010) Race * No Ethnic origins (including gypsies and travellers) No Nationality No Gender * No Culture No Religion or belief * No Sexual orientation including lesbian, gay and bisexual people * No Age * No Disability learning difficulties, physical disability, sensory impairment and No mental health problems * Gender reassignment * No Marriage and civil partnership * No 2. Is there any evidence that some groups are affected differently? No 3. If you have identified potential discrimination which can include associative discrimination i.e. direct discrimination against someone because they associate with another person who possesses a protected characteristic, are any exceptions valid, legal and/or justifiable? 4(a). Is the impact of the policy/guidance likely to be negative? (If yes, please answer sections 4(b) to 4(d)). No 4(b). If so can the impact be avoided? 4(c). What alternatives are there to achieving the policy/guidance without the impact? 4(d) Can we reduce the impact by taking different action? No Comments: Action Plan due (or Not Applicable): Name and Designation of Person responsible for completion of this form: Mr John Swinhoe, Estates Maintenance Manager Date May 2013 Names & Designations of those involved in the impact assessment screening process: Estates Department (If any reader of this procedural document identifies a potential discriminatory impact that has not been identified on this form, please refer to the Policy Author identified above, together with any suggestions for the actions required to avoid/reduce this impact.) For advice on answering the above questions please contact Frances Blackburn, Head of Nursing, Freeman/Walkergate, or, Christine Holland, Senior HR Manager. On completion this form must be forwarded electronically to Steven Stoker, Clinical Effectiveness Manager, (Ext ) together with the procedural document. If you have identified a potential discriminatory impact of this procedural document, please ensure that you arrange for a full consultation, with relevant stakeholders, to complete a Full Impact Assessment (Form B) and to develop an Action Plan to avoid/reduce this impact; both Form B and the Action Plan should also be sent electronically to Steven Stoker within six weeks of the completion of this form. IMPACT ASSESSMENT FORM A October 2010

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