MOVING TO ALTERNATIVE PREMISES (SERVICE/TEAM/STAFF) POLICY

Transcription

1 MOVING TO ALTERNATIVE PREMISES (SERVICE/TEAM/STAFF) POLICY DOCUMENT CONTROL: Version: 2 Ratified by: Risk Management Sub Group Date ratified: 21 st October 2015 Name of originator/author: Information Governance Manager Name of responsible Risk Management Sub Group committee/individual: Date issued: 2 November 2015 Review date: October 2018 Target Audience All staff

2 CONTENTS SECTION 1. INTRODUCTION 3 2. PURPOSE 3 3. SCOPE 3 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 3 5. PROCEDURE/IMPLEMENTATION 4 6. TRAINING IMPLICATIONS 8 7 MONITORING ARRANGEMENTS 9 8. EQUALITY IMPACT ASSESSMENT SCREENING 8.1 Privacy, Dignity and Respect 8.2 Mental Capacity Act PAGE NO 9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS REFERENCES APPENDICES APPENDIX A Equality Impact Assessment Template 11.2 APPENDIX B Handover of Responsibilities for Property, Personnel and Equipment in Accordance with Current Law and Legislation 11.3 APPENDIX C Handover of Responsibilities for Room/Office and Equipment in Accordance with Current Law and Legislation Page 2 of 16

3 1. INTRODUCTION 1.1 At times it becomes necessary for staff to move/change their base points from one building to another within Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) and non RDaSH operated buildings. This sometimes happens individually with one staff member changing from one team to another which could be within the same building or on a wider scale with whole team moving from building to building. This policy aims to guide staff through that process. 2. PURPOSE 2.1 The purpose of this policy is to ensure staff are aware how a successful move should be organised and to highlight ways of making the transition from one building to another smooth and incident free. The objective of the policy is to provide checklists for staff when moving that can be used generically across the estate by all staff and to give assurances to the Senior Management Team that accountability for all equipment and data has been covered. 3. SCOPE 3.1 This policy must be used by Service Managers when premises (or parts of premises) cease to be used for their current purpose, and are vacated by the individuals, teams, or organisation currently using them. The Service Manager must appoint a Project Manager with responsibility for the move. 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 The Board of Directors has a responsibility for the Trust having policies and procedures in place that meet local and national requirements and any relevant legislation. 4.2 The Accountable Director for this policy will be the Executive Director Business Assurance. 4.3 This policy is to be used as a guidance document by the Environmental Project Manager, Health and Safety Team, Information Governance Manager, Assistant Directors and Service Managers when moving staff around the estate. This policy is designed to be used when planning, during and post the move to ensure all issues are addressed prior to the moving day. 4.4 Line Managers are responsible for ensuring staff have access to and understand the information highlighted by this policy and must make sure this is shared by all staff involved in the move to ensure all regulations/policies and Law are complied with and to minimise the risk of an incident occurring. 4.5 It is the responsibility of each employee to adhere to this policy and all related documents. Page 3 of 16

4 5. PROCEDURE/IMPLEMENTATION 5.1 PRE-MOVE Care Quality Commission, (CQC) The Trust must inform the CQC when services move location, this is because services are registered to carry out regulated activities only at locations specified on the Trusts Statement of Purpose. Please contact the Policy and Standards Officer at least 12 weeks before the move to ensure that CQC can process the application form An Equality Impact Assessment (EIA) Appendix A must be completed to ensure that people with Protected Characteristics will not be disadvantaged by the move / change from one office / building to another, stipulating any reasonable adjustments to be made and assistance required Ensure appropriate planning required for the move is undertaken e.g. health and safety pace regulations, infection prevention and control involvement for clinical areas. Liaison with IT for activation / installation of new IT points, liaison with technical team for transfer of phone lines, liaison with the Records Manager for the disposal or transfer of records, liaison with purchasing for the transfer of water cooler and photocopiers, post collection etc The manager requesting the move must have the move authorised by the Head of Estates. Once a move is authorised the project manager must complete the checklists in appendix B & C in preparation for handover of property The service/team/staff moving (to be known from this point as The Team ) are to discuss roles and responsibilities during the move. A contact must be selected to liaise with the Facilities Team and to manage the checklist The team are to liaise with the Facilities Team in order to create a time table for the move. This time table/schedule of work, once agreed will not be altered by staff without firstly liaising with the Facilities Team. If any alterations are agreed then a revised copy of the timetable will be produced and distributed. Any costs to be incurred will be discussed with the team as appropriate and arrange for the provision of boxes for the move As per the time table the team will begin to pack items in boxes, ensuring these are in line with the Trusts back care policies, ready to move and begin to remove items unfit for recycling and put in the correct waste stream including emptying of drawers / filing cabinets ready for porters, (on Tickhill Road site only subject to availability to assist) Guidance to be cascaded to staff pre move includes: o Ensure that you have clear concise inventories of what you have packed into which boxes in order to keep track of these items. Page 4 of 16

5 o Ensure that boxes are correctly and clearly labelled and also correspond to the inventories for the rooms the boxes will be moved into in the next premise (as applicable). o Adhere to Safer Moving and Handling policy/procedure when moving boxes. o Ensure that items being packed from secure rooms are kept in marked secure boxes within a secure room whilst being stored prior to move. o Uphold the integrity of the security of these items at all times. o Do not leave any items loose next to boxes, always place items inside the boxes. o Do not leave any boxes in walk ways or obstructing fire exits o Do not stack boxes more than four high or within manual handling safe limits. o Ensure that all records that are for transfer to the new premises are boxed up securely in accordance with the Records Management Lifecycle Policy and Process. o Ensure that all records that are out of their retention periods (check the Trusts Retention Policy on the Intranet) are disposed of and recorded on a Disposal Certificate in accordance with the Records Management Lifecycle Policy and Process. If in doubt please contact the Records Manager. o Under no circumstances should any records be left on the premises after the moving day. o Ensure you have checked the CQC registered location As per the Checklist (appendix A), the Environmental Manager will arrange waste disposal on a regular basis in line with Waste Regulations and the Waste Management Policy The team is encouraged during this process to try and streamline by shredding as much non essential paperwork and throw out as many broken, damaged items as possible prior to the move and informing or adjusting relevant inventories If anyone has any queries regarding waste and which waste stream to use please contact the Environmental Manager Risk assessment will be completed to ascertain whether security guarding is required Ensure a Fire Marshal is based within each building as per Trust policy guidance 5.2 MOVING DAY During the move please be aware the Health and Safety legislation and RDaSH Policies still apply The removal company / on site Porters (on Tickhill Road Site only subject to availability to assist) will move all boxes and furniture on and off the vehicle, and in and out of the building. The team should not assist with this. Page 5 of 16

6 5.2.3 The Environmental Manager will liaise with the removal company regarding the RDaSH Health and Safety policy and the Control of Contractors Policy The removal company will liaise with Facilities regarding Health and Safety guidelines at all sites. This will also include parking appropriately, security, infection prevention and control etc The removal company are to follow the inventories created by the team to show which items are to be put in which room on which floor, cross referencing the descriptions on the boxes with the inventories The team are not allowed to recruit non NHS staff to assist in the move. Unless it has been procured through the Trust No visitors to the old or new premises/offices will be permitted on non-essential business. Only the team moving, Facilities staff, removal staff, authorised deliveries and invited NHS staff (i.e. Health & Safety, Infection Control, Waste Manager etc.) will be permitted to enter with valid I.D. or visitors badge No children or animals will be permitted onto the old or new premise/offices Staff are responsible for their personal possessions during the move e.g. handbags Identification badges must be carried at all times whilst on duty as detailed within the Security Policy, Employees Handbook and Dress Code Policy The security of the old and new premises/offices must be upheld at all times. E.g. no doors to be wedged open without constant staff monitoring. The overall responsibility for the security of the buildings at this time will fall to the Head of Service or designated move facilitator No movement either in or out of either site will take place out of normal working hours. All activity will take place between 8am and 6pm, unless to prevent loss of services and done at weekends If security guarding is required the Facilities Team will liaise with the guarding company regarding the Control of Contractors Procedure Outside the normal hours of 8am 6pm the security guarding post will be responsible for the security of the site they are situated at and will be answerable to the Facilities Manager Deliveries must be made by the front entrance (or an entrance chosen by all staff to enter that is staffed at all times by a staff member) Deliveries must be signed for and checked through by a staff member. Page 6 of 16

7 If a delivery driver needs access to a room in the building, they must be issued with a visitors badge, signed in and accompanied by a staff member If an alternative entrance is required for deliveries this entrance must be secured at all times If any alternative arrangements are required the team must liaise with the facilities team giving as much notice as possible Staff must be inducted into the new environment/ building by Estates or the Head of Service All keys and fobs for the previous premise/office must be handed in to the Facilities Manager by the end of the last day of moving or the next working day if this is not possible. 5.3 POST MOVE Ensure all equipment including phones & IT are functioning appropriately Ensure that all equipment, data, files, furniture etc are all accounted for Ensure that all boxes are returned to the removal company or stores and all other boxes are removed and disposed of appropriately During the first week of the move Senior Managers must ensure that all staff has been fully inducted into the new building and are aware of all staff facilities, fire exits, call points, refuge points etc. ensuring all Health & Safety and Fire regulations are explained Ensure all fobs, swipes & keys etc. are allocated to staff and signed for. A log must be kept of all allocations for the new building. One copy to be held by the Service Manager and/or Team Leader and one by the Facilities Manager. For old building handed to person taking over as per Appendix B. Once all have been allocated updated copies are to be held by the Head of Service / Building Administrator The Facilities Department will issue the team with a hand book for the new building (where appropriate) with information in relating to the building maintenance, policies, fire evacuation procedures etc The facilities team will organise a Premises Inspection (if appropriate). Any issues highlighted will be reviewed by the Facilities Team. A visit may be required by the Waste Officer, Records Manager, the Infection Control team, Health and Safety Team depending on the circumstances and the team moving Ensure that the old premises where applicable are secure where necessary and Appendix A or B filled out and distributed accordingly. Once the move has taken place, the project manager must revisit the vacated premises with the landlord (where appropriate) and Records Manager in attendance, and that all parties check Page 7 of 16

8 to ensure that there are no residual records, or other items, still on the premises Ensure communication regarding relocation is communicated to all necessary groups internally and externally including service users, carers, staff, payroll, other professionals etc Update information governance asset lists related to the move and circulate to IT and Information Governance representatives Data sweeps of the vacated building will be undertaken by the Trust s Security Advisor, a member of the Information Governance Team and the Records Manager In the new premise, it is the duty of all Fire Marshalls to assist the Manager in complying with the Fire Safety Policy. This will include, but is not exclusive to; Updating the Fire Manual Instructing staff on the fire safety aspects of the new premise such as fire escapes, alarm points, fire panel and fire safety equipment Assess and create new Personal Emergency Evacuation Plans for disabled staff and service users Plan to conduct a fire evacuation drill soon after taking over the premise to ensure that the plans are fit for purpose. Other fire safety duties which are required in the new premise. Advice can be sort from the Trust Fire Safety Advisors. 5.4 ADDITIONAL REQUIREMENTS Please note that if there are any requirements additional to this procedure which has not been included staff must liaise with the Facilities Team Access to the previous premise/office will be dependant on the future of the premise/office and its new use (i.e. will it be demolished, put up for sale or be rehousing new teams and services?). Discretion will be given to the Facilities Manager for this decision. 5.5 INCIDENT REPORTING If you become aware of any items that have been misplaced or damaged, these items must be recorded and reported through the appropriate channels e.g. any incidents occurring will require a Safeguard incident report to be completed, and liaison with the facilities team in a timely fashion as contractors may need to be contacted e.g. removal firm or furniture suppliers etc. 6 TRAINING IMPLICATIONS 6.1 There are no specific training needs in relation to this policy, but the following staff Page 8 of 16

9 will need to be familiar with its contents: o The Facilities Team o Health and Safety Team o Assistant Directors o Service Managers As a Trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through team meetings, one to one meetings and Team Brief. 7. MONITORING ARRANGEMENTS Area for Monitoring How Who by Reported to Frequency Policy Review of policy against best practice will be undertaken every three years Trust s Security Advisor Information Governance Manager Risk Management Sub Group Three yearly Incidents Review of incidents on Safeguard System as part of the annual incident report. Trust s Security Advisor Information Governance Manager Risk Management Sub Group Annually 8. EQUALITY IMPACT ASSESSMENT SCREENING Complete the attached EIA Screening Tool 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). Indicate how this will be met No issues have been identified in relation to this policy. Page 9 of 16

10 8.2 Mental Capacity Act Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible. Indicate How This Will Be Achieved. All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act (Section 1) 9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS Health & Safety Policy Statement & all Related Health and Safety Procedures Safer Moving & Handling Policy & Procedure Control of Contractor Procedure Security Policy & Procedure Information Governance Policy & Procedure Incident Reporting Policy Informatics Security Policy Records Management Lifecycle Process Information Lifecycle & Records Management Policy Medical Devices Policy 10. REFERENCES Health and Safety at Work etc Act 1974 Connecting for Health - Information Governance Toolkit The Data Protection Act (1998) The Computer Misuse Act (1990) Freedom of Information Act (2000) 11. APPENDICES Page 10 of 16

11 EQUALITY IMPACT ASSESSMENT TEMPLATE Business Division / Directorate: Name of Service, Title of Policy or Strategy, Name of Event: Equality Impact Assessment Undertaken by: 11.1 APPENDIX A Service: Policy : Event: Strategy: Date Undertaken Questions 1. What are the main aims and purposes of the policy / service / event or strategy? 2. Who is involved in delivering the service, implementing the policy or strategy / organising the event? (i.e. partnerships, stakeholders or agencies) 3. What information /data or experience can you draw on to provide an indication of the potential inclusive / exclusive results of delivering this service or event / implementing the policy or strategy to different groups of people and the different needs of people with protected characteristics in relation to this policy / service / event or strategy? Please utilise the following table to indicate the impact of the service / policy for the protected characteristics. Age Protected Characteristics Disability Gender reassignment Marriage and civil partnership Pregnancy and maternity Race Religion or belief Sex Sexual Orientation Disadvantaged Groups Positive Impact Negative Impact Neutral Impact Reasons for Impact Page 11 of 16

12 4. What positive impacts are there for this policy / service / event or strategy to better meet the needs of people with protected characteristics? 5. What action would be needed to ensure that the policy / service / event or strategy overcomes: Discriminatory negative impacts; Exclusion; Failure to meet the needs of people from across the protected characteristics. 6. Recommended steps to avoid discrimination and ensure opportunities for promoting equality and inclusion are maximised. Include: Options for action Explanation if no further action is required Lead responsible for overseeing actions Timescales Costs (where applicable) 7. Monitoring and reporting arrangements of EIA, for policies and strategies refer to section 7 of the Policy for the Development and Management of Procedural Documents. For services / events please include the following: How the equality impact of the service will be monitored; Frequency of monitoring; How the monitoring results will be used and where they will be published; Who will be responsible for reviewing monitoring results and initiating further action where required; Any changes that have been made to remove or reduce any negative impacts as a result of conducting the equality impact assessment? Any action points should be included in Business Division / Corporate action plans, with monitoring and review processes. Is further work / consultation required? If Yes please explain how this is to be carried out and the time frame for completion. Yes No The Equality Impact Assessment will be reviewed in line with changes to services, client or staff groups, legislation or policy review. Name : Designation : Signature: Date: Page 12 of 16

13 11.2 APPENDIX B Department Name Address line 1 Address line 2 Address line 3 Address line 4 HANDOVER OF RESPONSIBILITIES FOR PROPERTY, PERSONNEL AND EQUIPMENT IN ACCORDANCE WITH CURRENT LAW AND LEGISTLATION. 1. I [Insert name of outgoing person responsible for building] accept that I have a duty to handover responsibility for [building name] to [name of incoming person responsible or estates representative] ensuring I have where reasonably practicable considered and discussed all the bullet pointed categories at paragraph 3 whilst considering all related regulations. Name; [outgoing] Signature;[outgoing] Date;. 2. I [Insert name of incoming person or estates rep. responsible for the building] accept that I have a duty to takeover responsibility for [building name] from [name of outgoing person responsible] ensuring where reasonably practicable considered and discussed all the bullet pointed categories at paragraph 3 whilst considering all related regulations. Name;[incoming] Signature; [incoming] Date;. 3. TICK WHEN COMPLETE Codes, keys and fobs for external and internal use and record of remaining staff who have them Intruder alarm code, building emergency key holder and intruder alarm firm and all contracts and details pertaining to each. Any outstanding planned building alterations or maintenance records with relevant contacts. Any other contracts that are ongoing (photocopier etc,) expiry dates and associated paperwork. Gas/Electric meter readings A drawing of building marked with all fire fighting equipment, first aid points, IP points, phone extension numbers and names of staff remaining along with full postal address. A full and complete walk around of the building with access to every room, safe, cupboard, drawer or anywhere that can be locked Data protection issues, all patient and staff identifiable documents are handed over or removed from the building (disbanded services) All records beyond their retention period have been appropriately destroyed (and recorded on a disposal certificate and copy sent to Records Manager), those still active have been boxed up and transferred to new premises securely and those Page 13 of 16

14 that need transferring to the external storage provided have been done so via the Records Manager. All prescription forms are handed over removed and/or returned All medication checked and auditable records signed by both parties A briefing to give a short history of the site, regarding local security and any neighbour and parking issues. Discuss any site specific local procedures. Discuss any seasonal issues, poor lighting, drains blocking, gritting, access to site and heating. Give details of building owner, length of rental agreement and any clauses therein. Give details of waste collection routine. Give details of any stores, bloods, drugs or post deliveries/collection. Give an inventory of equipment held in association with service and building. Multi occupancy buildings give a list of team leaders Discuss with finance department any issues regarding opening or closing rental agreements. Discuss any health and Safety issues specific to site, Risk assessments COSHH, PPE etc. 4. Having carried out the Handover /Takeover copies of this form should be distributed to the following. Business Division Assistant Director* Head of Estates* Corporate affairs Finance* Safety Section/LSMS* Informatics Business assurance Prescribing and medicines management Workforce and organisational development Communications team to announce any changes. Human Resources. Information Governance Manager* TICK WHEN COMPLETE * Must receive a copy. Page 14 of 16

15 11.3 APPENDIX C Department Name Address line 1 Address line 2 Address line 3 Address line 4 HANDOVER OF RESPONSIBILITIES FOR ROOM / OFFICE AND EQUIPMENT IN ACCORDANCE WITH CURRENT LAW AND LEGISTLATION. 1. I [Insert name of outgoing person responsible for room/office] accept that I have a duty to handover responsibility for [office name, number] to [name of incoming person responsible or estates representative] ensuring I have where reasonably practicable considered and discussed all the bullet pointed categories at paragraph 3 whilst considering all related regulations. Name; [outgoing] Signature;[outgoing] Date;. 2. I [Insert name of incoming person or estates rep. responsible for the room/office] accept that I have a duty to takeover responsibility for [office name, number] from [name of outgoing person responsible] ensuring where reasonably practicable considered and discussed all the bullet pointed categories at paragraph 3 whilst considering all related regulations. Name;[incoming] Signature; [incoming] Date;. 3. TICK WHEN COMPLETE Codes, keys and fobs for room, office access door are handed over with a list of existing staff who have them Any outstanding planned building alterations or maintenance records with relevant contacts. Note any damages Any other contracts that are ongoing (photocopier etc,) expiry dates and associated paperwork Location of all fire fighting equipment, nearest emergency/fire exit, first aid points, IP points, phone extension numbers. Data protection issues, all patient and staff identifiable documents are handed over or removed from the room, office by departing occupants All prescription forms are handed over removed and/or returned All medication checked and auditable records signed by both parties Give details of building owner and nominated building manager. Give details of waste collection and domestic s routine. Give an inventory of equipment/ furniture and IT equipment being left behind. Discuss any health and Safety issues specific to room, office Risk assessments COSHH, PPE etc. Page 15 of 16

16 4. Having carried out the Handover /Takeover copies of this form should be distributed to the following. Building Manager/ Budget Manager Safety Section/LSMS ( Data sweep) Informatics (if IT being left behind) Communications team to announce any phone number changes. Human Resources. Information Governance Manager TICK WHEN COMPLETE Page 16 of 16