Executive Director of Nursing and Operations Tony Gray Head of Safety and Patient Experience Craig Newby Patient Safety Officer

Transcription

1 Document Title Reference Number Security Management Policy NTW(O)21 Lead Officer Author(s) (name and designation) Executive Director of Nursing and Operations Tony Gray Head of Safety and Patient Experience Craig Newby Patient Safety Officer Ratified By: Senior Management Team Ratified Date: October 2012 Implementation Date October 2012 Date of full implementation November 2012 Review date Dec 2017 Version V03.7 Review and Amendment Log Version Type of change Date V03 Review Oct 12 Description of change Reviewed policy documentation within sections:, 3, 6, 7, and Appendices A, B and C From November 2012, Trust wide Policy Group approve policy documentation V03.1 Update Nov 13 V03.2 Update Feb 15 V03.3 Update Oct 15 V03.4 Update Mar 16 Inclusion of NEW SM- PGN-08 Trust Search Dog Procedure Inclusion of SM-PGN-15 Taser (CS/PAVA) Extension to Review Mar 16 Updated Index inclusion of SM-PGN Joint Missing Persons Guidance Extension to Review June 2016 V03.5 Update Jun 16 Extended Review to Dec16 V03.6 Update Dec 16 Extended Review June 17 V03.7 Update Jun 17 Extended Review Dec 17 This policy supersedes, which should now be destroyed: NTW(O)21 V03.6 Reference Number Title Security Management Policy

2 NTW(O)21 - Security Management Policy Section Contents Page No: 1 Introduction 1 2 Purpose 1 3 Duties and Responsibilities A professional approach to managing security in the NHS 2 4 Access to Security Management Advice 5 5 Development of Practice Guidance Notes 5 6 Consultation and communication with stakeholders 5 7 Approval and review of Document 6 8 Definitions of Terms used 6 9 Equality Impact Assessment 6 10 Training 6 11 Implementation 7 12 Monitoring and Compliance of Security Management Policy and Practice Guidance Notes 7 13 Monitoring Compliance 7 14 Standards/ Key Performance Indicators 8 15 Fraud and Corruption 8 16 Fair Blame 8 17 Associated documentation 8 18 References 8 Standard Appendices A Equality and Diversity impact Assessment Form 9 B Communication and Training Needs Information 12 C Monitoring Tool 13 D Policy Notification Record Sheet - click here Appendices listed separately to the policy 1 Terms of Reference for Trust Wide Security Management Group 2 Contact Details

3 Practice Guidance Notes (PGNs) listed separate to policy U/D = under development PGN Number Title Issue SM-PGN 01 Closed Circuit Television Systems Date Issued Review Date V03- Issue 5 Feb 17 Jun 17 SM PGN 02 Lone Working V03- Issue 6 Feb 17 Jun 17 SM PGN 03 Use of Mobile Comm. Devices V03- Issue 3 Nov 16 May 17 SM PGN 04 Nuisance and Malicious Calls V03- Issue 5 Feb 17 Jun 17 SM PGN 05 Dealing with Bomb Hoaxes and suspect packages Draft SM PGN 06 Police Liaison 5 Feb 17 Jun 17 SM-PGN-06.1 Joint Missing Persons Guidance 1 Mar 16 Mar 19 SM PGN 07 Staff Support for the Deterrence, Prevention, Detection and Investigation of Physical and Non-Physical Assaults included within SM-PGN-11 SM PGN 08 Trust Search Dog Procedure V02- Issue 1 Feb 17 Feb 20 SM-PGN-09 SM-PGN-10 Identicom Lone Worker Protection System Hospital Lockdown in Emergency situations 6 Feb 17 Jun 17 5 Feb 17 Jun 17 SM-PGN-11 Working with Police and Criminal Justice System-replacing Management of Offences V03- Issue 1 Oct 16 Oct 19 SM-PGN-12 Hopewood Park - CCTV U/D SM-PGN-13 Hopewood Park -Access-Egress U/D SM-PGN-14 Hopewood Park - Staff attack system U/D SM-PGN-15 NEW - Guidance on the aftercare with the use of Taser, CS Incapacitant Spray (CS) and PAVA Incapacitant Spray (PAVA) 2 Aug 15 Feb 18 SM-PGN-16 Covert CCTV Recording U/D

4 1 INTRODUCTION NTW(O) Security Management within the National Health Service (NHS) is now the responsibility of NHS Protect, the remit of NHS Protect is defined in law under Statutory Instrument 2002 no This document defines the policy and practice guidance notes to be followed within the (the Trust) for all aspects of Security Management. 1.3 The Trust will work with the other agencies to tackle security management issues across the NHS through a range of generic actions: Creating a pro-security culture. Deterring those who may be minded to breach security. Preventing security incidents or breaches from occurring. Detecting security incidents or breaches. Investigating security incidents or breaches. Applying sanctions against those responsible for security incidents or breaches. Seeking redress through criminal and civil justice systems from those responsible for security incidents. 1.4 All staff working within the Trust have a responsibility to ensure they work in a safe manner and must familiarise themselves with the correct procedures contained in this document. Those in charge of wards and departments are responsible for ensuring that their staff, especially new starters, locum and agency staff, follow Practice Guidance Notes (PGNs) within this policy document. Copies of the policy document will be available in all wards and departments. 1.5 The procedures also apply to medical staff, nursing staff and other types of staff from other NHS Trusts or from private practices, who are contracted to work in the Trust on a sessional basis. Managers who contract for these services must make it explicit within the written contract that these sessional staff must follow the procedures described. 1.6 The concepts of patient safety, focussed care and patient empowerment provide a fresh approach to some long-established practices. Similarly, the principles of Clinical Governance and Risk Management, which are high on the Trust s agenda, are embodied in the procedures herein. 2 PURPOSE 2.1 The Trust places the health, safety and welfare of its patients, carers, staff and visitors high amongst its priorities and will ensure it maintains safe and secure conditions throughout the organisation. It will work closely with partner organisations where the health, safety and welfare have shared ownership, to ensure co-operation at all levels. 1

5 2.2 The relevant primary legislation concerning these functions are: NTW(O)21 The Health and Safety at Work etc. Act 1974 The Management of Health & Safety at Work Regulations (as amended) 1999 Counter Fraud and Security Management Service Regulations (as amended) The Policy is also based on the recommendations and requirements of specific Security Management Service documents, these will be updated as new guidance is issued or replaced: A Professional Approach to Managing Security in the NHS. Tackling Violence Against Staff. Non Physical Assaults Explanatory Notes Not Alone A Guide for the Better Protection of Lone Workers in the NHS. Safe & Se(cure) - How You Can Help the NHS Protect Itself. NHS Security Manual. 2.4 The Trust requires all staff to have a working knowledge of this policy and to be familiar with above listed rules and guidelines. Information, including updates will be available via Local Security Management Specialists (LSMS). In addition to this new information will be shared via the Security Management Group. 2.5 Failure to comply with this Security Management Policy may result in disciplinary action being taken 2.6 Staff are personally accountable for their practice and in the exercise of their professional accountability must Act always in such a manner to promote and safeguard the interests and well being of patients. Ensure that no act or omission on their part or within their sphere of responsibility is detrimental to the interests, condition or safety of patients, staff and visitors. Maintain and improve their professional knowledge and competence. Acknowledge any limitations in their knowledge and competence and decline any duties or responsibilities unless able to perform them in a safe and skilled manner. 3 DUTIES AND RESPONSIBILITIES - A Professional Approach to managing Security in the NHS 3.1 Chief Executive The Chief Executive on behalf of the Trust retains ultimate accountability for the Health, Safety and Welfare of all patients, carers, staff and visitors however key tasks and responsibilities will be delegated to individuals in accordance with the content of this policy. 2

6 3.2 Executive Director of Nursing and Operations NTW(O) The Executive Director of Nursing and Operations in their capacity as the Trust s nominated Security Management Director and in line with the Security Management Service s direction shall assume responsibility on behalf of the Board of Directors for all aspects of Security Management within the Trust. They will ensure that all management arrangements are in place to ensure compliance with this policy. 3.3 Non Executive Director The Non-Executive Director has been appointed at board level to support the Security Management Director, to assure that the Security Management Directions are carried out. 3.4 Deputy Director of Clinical Governance The Deputy Director of Clinical Governance shall ensure all security provisions are administered in line with all other Trust policies and will liaise with all clinical specialities to ensure that the Trust can comply with all its Clinical Governance responsibilities. 3.5 Group Directors It will be the responsibility of Group Directors to own and action any Group based recommendations, which are in relation to security management. Where necessary Group Directors will provide any necessary resources including management support, which may be needed to mitigate any security management risks. 3.6 Local Security Management Specialist s (LSMS) As part of the Security Management Service s direction every Trust must appoint an individual to assume the day to day responsibility of security management to assist the Security Management Director to implement all aspects of security provision within the Trust. For the purpose of this policy and all Trust practice guidance notes (PGNs) the Trust s Local Security Management Specialists shall assume this responsibility and assist the Security Management Director to comply with all directions from the Security Management Service The Trusts Local Security Management Specialist s will: Undergo professional and accredited security management training Undertake security management work in accordance with the legal directions and the NHS Security Management Manual Carry out Security Risk Assessments both in a pro-active manner to prevent security incidents or breaches and re-actively following reported security incidents and produce recommendations and guidance for improvements Chair the Trusts Health, Safety and Security Group. 3

7 Be a central link for all security issues across the organisation Be the Single Point of Contact (SPOC) for security management NTW(O)21 Monitor police investigations and update the member of staff and the Trust on progress Ensure details of incidents are recorded on the Trust System Ensure compliance with Care Quality Commission Essential Standards of Quality and Safety - March Produce work plans to be signed off by the Security Management Director and sent to NHS Protect Produce an annual report on security management for assurance and present to the Board of Directors 3.7 Security Risk Assessments The Trust carries out security risk assessments in a number of different ways and for a number of different reasons. Security risk assessments carried out pro-actively as part of new project design, will be captured in the design specifications of buildings, and will include such things as CCTV, Access / Egress control, staff attack systems, security lighting etc. Security risk assessments carried out as part of general risk assessments through group risk register activity, this information and the resultant actions will be managed through the groups, and reported through their quality and performance groups. Re-active security risk assessments following incidents, complaints and claims. These will be fed into the groups and also where appropriate through to the Group Business Meeting and Senior Management Team. This will be dependant on escalation of risk Action Plans From the above information there will be a number of action plans created to fulfil the requirements of each of the above assessments. Action plans can be in the form of individual specifications drawn up for provision of new security equipment such as CCTV. Action plans can be in the form of minutes from groups or committees, with identified leads. Action plans created as a result of risk register activity. Action Plans can be as result of findings from Incidents, Complaints and Claims. 4

8 NTW(O) Head of Facilities As part of this policy the Head of Facilities shall ensure the effectiveness of day-to-day security provision across the Trust and take on board all aspects of the NHS Protect standards. 3.9 Health, Safety and Security Group The responsibilities of the above are identified in the Terms of Reference (Appendix 1) at the end of this policy. 4 ACCESS TO SECURITY MAGEMENT ADVICE 4.1 In the first instance all staff should access any advice about Security Management strategic issues from the Trust s Local Security Management Specialist. In absence of this then advice should be sought from the Security Management Director. For contact details see Appendix For day-to-day operational security issues Facilities Management should be contacted. 5 DEVELOPMENT OF PRACTICE GUIDANCE NOTES 5.1 The Local Security Management Specialists will develop specific practice guidance notes to cover immediate risk issue areas. 5.2 Practice guidance notes will also be developed to reflect the standards of the NHS Security Manual if Trust policies or processes do not already cover these areas. 6 CONSULTATION AND COMMUNICATION WITH STAKEHOLDERS 6.1 This is an existing policy with additional / changed content that relates to operational and / or clinical practice and was therefore circulated to the following for a four week consultation period: Senior Management Team Planned Care Group Directors Specialist Care Group Directors Urgent Care Group Directors Psychological Services Clinical Governance and Nursing Directorate Trust Allied Health Professions Service Steering Group Finance, IM&T, Estates and Performance Staff-side Trust Pharmacy Workforce Allied Health Professionals Strategic Forum Communications 5

9 NTW(O)21 7 APPROVAL AND REVIEW OF DOCUMENT 7.1 This policy was approved by the Senior Management Team and will be reviewed 3 years from date of issue, unless by exception, i.e. due to change in legislation or standards etc. 7.2 The Trust Health, Safety and Security Group as part of its Terms of Reference will have responsibility to review the Security Management Arrangements on behalf of the Trust and provide assurance to the Quality and Performance Committee. 8 DEFINITIONS OF TERMS USED CFSMS LSMS PGN SMS SPOC Counter Fraud and Security Management Specialists Local Security Management Specialists Practice Guidance Note Security Management Specialist Single Point of Contact Security Risk Assessment A security risk assessment is a proactive or re- active assessment in line with the guidance offered by NHS Protect carried out by an accredited local security management specialists 9 EQUALITY AND DIVERSITY ASSESSMENT 9.1 In conjunction with the Trust s Equality and Diversity Officer this policy has undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. 10 TRAINING (See Appendix B 10.1 Preventing security incidents, loss, criminal damage and violence and aggression towards staff, patients and others is a Trust priority. By providing the appropriate security management training the Trust seeks to: Ensure violence and aggression is managed appropriately and in line with Trust expectations. Ensure appropriate sanctions are sought where criminal activity has taken place within the Trust. Develop a positive security management culture within the Trust. Develop clear lines of communication in relation to security management, including the development of inter-agency groups. Meet its legal duty to protect the health and safety of staff. Ensure advancements in technology are considered as part of security management risk controls. 6

10 NTW(O)21 Undertake comprehensive risk assessments around the protection of property and assets as well as the security of Trust premises. Develop an integrated approach to security preparedness and resilience in conjunction with the Trust Health Emergency Planning and Business Continuity Facilitator To this end the Trust will provide Security Management awareness training as part of the Statutory and Mandatory Training arrangements. In addition to this each Local Security Management Specialist will be expected to attend quarterly NHS Protect updates as well as any formal training provided by NHS Protect Levels of training are identified in the training needs analysis and are included within the Training Guide which can be accessed via this link 11 IMPLEMENTATION 11.1 Managers at every level are expected to implement the requirements contained within this policy in conjunction with their risk management arrangements. Those arrangements include hazard identification, ensuring remedial action, monitoring and review of their safe systems of work This will be monitored at the respective Group Quality and Performance meeting. 12 MONITORING AND COMPLIANCE OF THE SECURITY MAGEMENT POLICY AND PRACTICE GUIDANCE NOTES 12.1 There are a number of ways in which the compliance to this policy and practice guidance notes will be monitored (see Appendix C Audit Monitoring Tool). 13 MONITORING COMPLIANCE 13.1 Security Management will be monitored on an annual basis by NHS Protect as part of their Quality Assurance programme. This process assesses the trust against 45 security management standards. The initial phase comprises of a self assessment, which is then assessed by NHS Protect. The results of the assessment will be shared with other external bodies e.g. Health and Safety Executive, Care Quality Commission and internal governance groups e.g. Health, Safety and Security group, Audit Committee Any recommendations or actions will be built into the Annual Work Plan, which is agreed with the Trust Security Management Director and NHS Protect. 7

11 14 STANDARDS/KEY PERFORMANCE INDICATORS NTW(O) Care Quality Commission, Essential Standards of Quality and Safety March NHSLA Risk Management Standards Safe Environment 14.3 NHS Protect Standards NHS Protect Quality Assurance Programme 15 FRAUD AND CORRUPTION (Only if appropriate) 15.1 In accordance with the Trust s policy NTW(O)23 Fraud and Corruption/Response Plan, all suspected cases of fraud and corruption should be reported immediately to the Trust s Local Counter Fraud Specialist or to the Executive Director of Finance. In some circumstances a Security Management incident may include elements of Counter Fraud, and vice versa. Where this is the case there must be robust communication between Local Security Management Specialists (LSMS) and Local Counter Fraud Specialists (LCFS) Where information regarding fraud and security is released as an alert, the alert protocol, Appendix 4, will be completed by either the LSMS or the LCFS and shared respectively. 16 FAIR BLAME 16.1 The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken. 17 ASSOCIATED DOCUMENTATION NTW(O)01 - Development and Management of Procedural Documents NTW(O)05 Incident Policy and Practice Guidance Notes NTW(O)21 - Security Management Policy Practice Guidance Notes 18 REFERENCES Counter Fraud and Security Management Service - Statutory Instrument 2002 no The Health and Safety at Work etc. Act 1974 The Management of Health & Safety at Work Regulations (as amended) 1999 Counter Fraud and Security Management Service Regulations (as amended)

12 NTW(O)21 Equality and Diversity Impact Assessment Screening Tool Appendix A Names of Individuals involved in Review Date of Initial Screening Review Date Service Area / Directorate T. Gray July 2007 Sept 2008 Trustwide C. Rowlands V02 - Sept 08 Feb 2012 T. Gray V03 Oct 2012 Policy or Service to be Assessed Security Management Policy V03 Describe the aims, objectives or purposes of the Policy or Service Is this a new or existing Policy or Service? Existing Security Management Policy is a statement of intent to protect people and property within the NHS. It is a legal requirement under the Secretary of State Directions for Security Management. It states the specific responsibilities from the Board of Directors down to employees. Are there any associated objectives of the Policy or Service? If so what are they? Security Management is inter-related with all other safety policies. Does the policy unlawfully discriminate against equality target groups? No Does the policy promote equality of opportunity for equality target groups? Not Applicable Does the policy or service promote good relations between different groups within the community, based on mutual understanding and respect? Not Applicable 9

13 NTW(O)21 Equality and Diversity Impact Assessment Screening Tool Which equality target groups of the population do you think will be affected by this policy or function? Equality Target Group (code in bold type) Black and Minority Ethnic People (including gypsy/travellers, refugees and asylum seekers) BME Women and Men WM What positive and negative impacts do you think there may be for each equality target group(s)? People in Religious/Faith groups RF Disabled People DP Older People OP Children C Young People YP Lesbian Gay Bisexual and Transgender People LGBT People involved in the criminal justice system CJS Staff S Any other group(s) AOG 10

14 NTW(O)21 Equality and Diversity Impact Assessment Screening Tool Screening Tool Checklist Summary Sheet Positive Impacts (Note the code of groups affected) Negative Impacts (Note the code of groups affected) None Additional Information and Evidence Required Recommendations None From the outcome of the Screening, have negative impacts been identified for race or other equality groups? No If yes, has a Full Impact Assessment been recommended? If not, why not? Manager s signature: Tony Gray Date: 18 October

15 NTW(O)21 Communication and Training Check list for policies Appendix B Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy Is this a new policy with new training requirements or a change to an existing policy? If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below. Existing Policy Minimal change in knowledge needed other than understanding the content of the policy and the responsibilities it places on staff. Local Security Management Specialists will be subject to ongoing training requirements to help maintain their knowledge base and undertake their responsibilities Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice? Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHSLA etc. Please identify the risks if training does not occur. Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training. Is there a staff group that should be prioritised for this training / awareness? Please outline how the training will be delivered. Include who will deliver it and by what method. Local Security management Specialists must be accredited as specified under NHS Protect Standards Specific training is required for Local Security Management Specialists. As identified in the Training Needs Analysis Awareness of policy implementation via e- bulletin. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session; E Learning Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc. Forms part of Statutory and Mandatory Training. Forms part of the Trust induction programme Forms part of the Staff Handbook Local Security Management Specialists 12

16 NTW(O)21 Statement Monitoring Tool Appendix C The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework. NTW(O)21 Security Management Policy - Monitoring Framework Auditable Standard/Key Performance Indicators Non-Executive and Executive Director Review of local Security Management Specialists annual work plan Independent scrutiny of annual work plan and annual report by Area Security Management Specialist Compliance with Care Quality Commission, Essential Standards Outcome 10 Safety and Suitability of Premises Outcome 7 Safeguarding People who use Services from Abuse Review of Security Management arrangements by both the The Trust Health, Safety and Security Group and Quality and Performance Committee Review of NHS Security Management Standards Frequency/Method/ Person Responsible Annually /Executive Director of Nursing and Trust Chairman Annually / Area Security management Specialist As required for Care Quality Commission Bi-Monthly / Monthly Head of Safety / Patient Experience Annually Local Security Management Specialists Where results and any associated action plan will be reported to, implemented and monitored; (this will usually be via the relevant governance group). Health, Safety and Security Group National body assurance processes in line with legislation and quality standards. National body assurance processes in line with legislation, quality standards. Health, Safety and Security Group / Quality and Performance Committee Health, Safety and Security Group / Patient Safety Group / Audit Committee The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out. 13