Low Secure Unit (LSU) Operational Procedure

Document level: Trustwide (TW) Code: GR43 Issue number: 2 Low Secure Unit (LSU) Operational Procedure Lead executive Authors details Type of document Target audience Document purpose Director of Nursing Therapies Patient Partnership Lead Occupational Therapist, Secure Services Policy All CWP staff The aim of this document is to give CWP Low Secure services clear guidance and direction to enable them to maintain safe environments for all staff and service users and also to give assurances to the North West Low Secure Commissioning board regarding all security standards. Approving meeting CWP East Governance & Risk Meeting Implementation date 18 th June 2015 CWP documents to be read in conjunction with HR6 CP6 GR25 CP38 CP12 GR1 GR3 GR8 CP10 GR46 CP25 HR22 Trust-wide learning and development requirements including the training needs analysis (TNA) The management of violence and aggression (incorporating verbal threats to staff and offensive weapons) Psychiatric Emergency Team policy Seclusion policy The searching of patients and environments (including the use of Police dogs) Incident reporting and management policy Risk management policy Security policy Safeguarding adults policy Surveillance System (CCTV) policy Therapeutic Observation Policy for Inpatients Supervision Policy Document change history New sections added which include: updated relational security information, transportation, Webex, safeguarding, control of electronic devices, control of violent and sexually inappropriate material, Relationships, Anti-bullying, What is different? Advocacy, low secure inpatient staff training, peer supervision and reflective practice, York House Security procedures, Use of DigiX radios and updated restricted items list. Appendices / electronic forms What is the impact of change? Improved clarity of security procedures, meets with Forensic Quality Network National Standards. Training requirements Financial resource implications No - Training requirements for this policy are in accordance with the CWP Training Needs Analysis (TNA) with Learning and Development (L&D) No Page 1 of 52

External references Equality Impact Assessment (EIA) - Initial assessment Yes/No Comments Does this document affect one group less or more favourably than another on the basis of: - 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 disabilities, physical disability, sensory impairment and mental health problems No Is there any evidence that some groups are affected differently? No If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? Is the impact of the document likely to be negative? No - If so can the impact be avoided? N/A - What alternatives are there to achieving the document without N/A the impact? - Can we reduce the impact by taking different action? N/A Where an adverse or negative impact on equality group(s) has been identified during the initial screening process a full EIA assessment should be conducted. If you have identified a potential discriminatory impact of this procedural document, please refer it to the human resource department together with any suggestions as to the action required to avoid / reduce this impact. For advice in respect of answering the above questions, please contact the human resource department. Was a full impact assessment required? No What is the level of impact? Low To view the documents Equality Impact Assessment (EIA) and see who the document was consulted with during the review please click here Page 2 of 52

Content 1. Introduction... 4 2. Definitions... 4 3. Procedure... 5 3.1 Role of the shift Coordinator / Nurse in Charge... 5 3.2 Role of the Security Officer... 5 3.3 Role of Low Secure unit staff... 6 3.4 Physical Security... 7 3.5. Transportation and CWP unit vehicles... 9 3.6. Ward based security and restrictions... 9 3.7 Personal searches... 12 3.8 Unit lock down... 13 3.9 Visitors to the unit... 13 3.10 WEBEX virtual visiting and conferencing facility.... 17 3.11 Safeguarding incidents... 17 3.12 Section 17 Leave (escorted and unescorted leave)... 18 3.13 Missing Patients and Absent Without Leave (AWOL)... 19 3.14 Control of electronic devices... 20 3.15 Violent and sexually inappropriate material... 21 3.16 Relationships... 23 3.18 Anti-bullying... 25 3.19 Advocacy... 25 4. Low secure inpatient staff security training... 26 5. Peer-Group Supervision and Reflective Practice Sessions:... 27 6. York House security Procedures.28 Appendix 1 - Restricted and Prohibited Items... 31 Appendix 2 Security Responsibilities of the Shift Coordinator / Nurse in Charge... 32 Appendix 3 Security Responsibilities of the Nominated Security Officer... 33 Appendix 4 - All Low Secure Staff and Operational Security Matters For Each Shift... 35 Appendix 5 - TRAKA Standard Operating Procedure (Saddlebridge)... 36 Appendix 6 - TRAKA Standard Operating Procedure (Alderley)... 37 Appendix 7- Potentially Dangerous Missing Items Flowchart... 38 Appendix 8 - Instructions for use of DigiX Two Way Radios;... 39 Appendix 9 - Soss Moss DigiX Communication Radio Protocol. Quick Read Version.... 40 Appendix 10 - Service Users agreement for use of mobile phone within Low Secure Services... 41 Appendix 11 - Section 17 Leave Of Absence Form... 42 Appendix 12 - Serious and Untoward Incidents Initial Reporting Form... 44 Appendix 13 - Unit Vehicle... 45 Appendix 14 - Daily Security Checklist... 46 Appendix 15 - Service User Security Items... 47 Appendix 16 Daily Cutlery Checklist... 48 Appendix 17 Leave Record... 49 Appendix 18 - Key, fob, DigiX radio and alarm allocation identification form... 50 Appendix 19 Unit Vehicle Key Allocation Form... 51 Appendix 20 Record of Searching... 52 Page 3 of 52

1. Introduction As part of the Cheshire and Wirral Partnership NHS Foundation Trust, all Low Secure Units are committed to improving and promoting security by minimising risk for staff, patients and visitors. It is recognized that CWP Low Secure units have different operational needs regarding their services however the aim of this policy is to set the security priorities and standards in accordance with external regulations. This procedure sets out a framework for the management of security both internally and externally which is in compliance with the Low Secure Commission standards. Effective security is the responsibility of all trust employees. All staff must regularly update themselves as to the provisions of this policy and adhere to it at all times. In addition to this policy all staff should make themselves aware of related Trust policies and procedures. It is the responsibility of all staff to maintain a safe, secure therapeutic working environment. Security should play a positive and supportive role in the treatment of service users who require low secure care. Security should not be seen as negative or as preventing things from happening, but rather as a positive, providing the structure within which the clinical care can be safely delivered. Security is not only about the physical security of the building but is achieved through the therapeutic relationships developed with service users, effective communication and a high degree of observation. Relational security relies entirely on staff developing constructive, professional relationships with their colleagues and therapeutic relationships with the service users in their care. There must be a commitment to the provision of therapeutic activity and the recognition of each service users individual needs. Awareness of the therapeutic importance of physical, relational and procedural security is valuable in ensuring safe treatment plans for patients as well as in the organisation and management of all secure services. Relational security is by far the most important element in the maintenance of therapeutic progress and in ensuring that the whole security system works. To achieve the ultimate secure care environment three components must be provided; physical security, procedural security and relational security. Patients in low secure units will receive all of their care and treatment within the secure perimeter - or hospital grounds if authorised by the care team - unless authorised leave under section 17 of the Mental Health Act 1983 has been granted. 2. Definitions Low Secure definition Security door Master key Lockdown (refer to the CWP Trust GR8 Security Policy for further advice) External areas Low secure units deliver intensive, comprehensive, multidisciplinary treatment and care by experienced and competent staff for service users who demonstrate disturbed behaviour in the context of a serious mental disorder and who require the provision of security. This is according to an agreed philosophy of unit operation underpinned by the principles of rehabilitation and risk management. Such units aim to provide a homely secure environment, which has occupational and recreational opportunities and links with community facilities. Patients will be detained under the Mental Health Act and may be restricted on legal grounds needing rehabilitation usually for up to 2 or 5 years. A locked access or control point which only CWP staff can open. A master key operates a set of several locks. Usually, there is nothing special about the key itself, but rather the locks into which it will fit. These locks also have keys that are specific to each one and cannot operate any of the others in the set. Access and usage of the Master Key will be through the Security Officer with the nurse in charge authorisation only. Non-CWP staff will not have access to the Master Key at any time. Lockdown is the process of controlling the movement and access, both entry and exit, of people (staff, patients, and visitors) around a site or other specific building/area. This will be in response to an identified risk, threat or hazard that might impact upon the security of patients, staff and assets or, indeed, the capacity of that facility to continue to operate. A lockdown is achieved through a combination of physical security measures and the deployment of personnel, (DH 2009). All areas adjacent to the unit which includes windows, gates and locks. Page 4 of 52

Restricted Areas Prohibited / restricted items Electronic device Pornography Fobs Restricted areas are defined as areas within the unit which by virtue of their degree of isolation or limited security which must remain locked at all times. Items that can present a hazard or breach essential security need to be controlled. (Refer to Appendix 1) Any device with recording, photographic or internet access facility e.g. cameras, camcorders, mobile phones, lap tops, ipods / pad / tablets, net books, and portable games consoles. Refers to material which is either of a sexually explicit nature or which depicts sexually or violently abusive acts or themes. Refers to staff fobs only and not to patient fobs. It is a portable wireless security device for use on doors where a higher level of security protection or control is required. It can also be individualised to allow the user access to specific areas only. 3. Procedure Ensuring a pro-security culture across all clinical areas is fundamental for ensuring all services remain safe for all staff and Patients. Security is the responsibility of all members of staff and it is important that it is reviewed at agreed times. Procedural security involves policies and procedures, these need to be clear to give people confidence in what they are doing and ensure they are doing the same thing. Physical security describes measures that prevent access to a facility or resource. This can be as simple as a locked door and can include control of items brought in or taken out of the secure perimeter. Relational Security refers to the knowledge and understanding staff have of a service user and of the environment, and the translation of that information into appropriate responses and care DoH 2010. Any security breaches which may have occurred must be documented and handed over to an appropriate senior member of staff who will then take the appropriate action. This includes relational security concerns. Any staff found to have been negligent in their actions and/or in breach of any security measure within this policy may subject to an investigation and possible disciplinary action in accordance with CWP policy. 3.1 Role of the shift Coordinator / Nurse in Charge The nurse in charge/ shift co-ordinator is responsible for all operational day to day care and security matters. The role is integral to the planning and smooth running of each shift. The role requires the individual to plan ahead but to work flexibly as required. This role is integral to maintaining safe environments and for the allocation of staff roles to support both the care and security function of the unit. It is the responsibility of the Nurse in charge / shift co-ordinator to ensure that any issues relating to physical, procedural or relational security are dealt with appropriately as soon as they have been made aware of these. The shift Coordinator / Nurse in Charge must ensure that all security breaches are reported and acted on in accordance with CWP policy (refer to Appendix 2 for further advice) 3.2 Role of the Security Officer The Security Officer has responsibility for the timely and accurate reporting of all security matters to the nurse in charge / shift co-ordinator. The Security Officer role demands that the nominated staff member remains free from other duties that would prevent them fulfilling their security role in a timely manner. Staff members in this role will not take part in level 3 and 4 service user observations, escorts or respond to other clinical emergencies outside the clinical area. It is the - responsibility of the nurse in charge/ shift co-ordinator to ensure that this occurs (refer to Appendix 3 for further advice) The Security Officer role may be undertaken by staff rotationally (one staff only at any time) and will demand some flexibility. Such flexibility requires excellent communications between the shift team, the use of problem solving approaches and decisions in response to any particular staffing/situational Page 5 of 52

difficulties that may occur. Where practicable this communication should initially be between the security officer and the nurse in charge. 3.3 Role of Low Secure unit staff Each Low Secure Service staff member has a responsibility for ensuring compliance with this policy and for assisting with the operational day to day security matters. As part of this responsibility each staff member may be designated on commencement of duty to carryout physical checks of internal security prior to commencement of clinical duties (refer to Appendix 4 for further advice). All Low Secure Unit staff (including clinical and non-clinical staff) a) ID badges and Lone Working All CWP staff must be wearing and displaying their personal identification badge on a lanyard prior to entering the building; All non-inpatient staff must not be issued with a pass key if they are not working within the inpatient areas; All non-inpatient staff and visiting professionals are responsible for signing in and out and for recording the purpose of their visit at the reception point; All staff and visiting professionals are responsible for ensuring compliance with CWP Trust GR33 Lone Worker Policy when working in isolation. b) TRAKA, Pass Keys, Alarm and Key Fobs Normally no clinical security items/keys or fobs must be taken outside the building where they are issued. The only exception to this will be the nominated Crisis Support Team staff member when responding to an emergency call from the partner Low Secure unit, where response time is essential to maintain safety. At no other time will security items / keys or fobs be taken outside the responsible unit. It is the responsibility of each staff member that: Prior to being issued with any security items they are in receipt of a belt, key pouch and key strap; They are in receipt of a TRAKA PIN number and are aware of the TRAKA Standard Operating Procedure (see Appendix 5 & 6 ) All pass keys must be attached to the key strap before leaving the TRAKA cabinet area; All pass keys must be secured within the key pouch when not in use; Pass keys must not be removed from the key strap away from the TRAKA cabinet area; Service users must not be allowed to handle or closely view the pass keys; Personal keys must not be placed onto the key strap; All pass keys and fobs must be securely attached to the staff member at all times using approved methods as outlined above; Staff are responsible for the safekeeping of their pass key, fob and personal alarm at all times; At no time will staff allow patients access to the pass keys, fobs or alarms including keys that allow access to other on site areas such as York House, tool shed, unit vehicles. All staff must return and their pass key, fob and personal alarm to the TRAKA cabinet when going off duty or leaving the clinical unit.(other than Crisis Support Team, see above) c) Bank staff Bank staff are issued with a Bank Home Fob by the security officer allowing them to access a master key and SAS alarm from the TRAKA cabinet. It is the responsibility of the security officer to ensure that the bank member of staff has been issued a pouch and key strap for the duration of their shift and that they have been Page 6 of 52

informed that the key is to remain attached to them via their key strap at all times whilst on the unit. Bank staff will be informed by the security officer how to operate their SAS alarm prior to them entering the unit. d) Damaged or broken pass keys If any key is broken off whilst in the lock barrel staff must remain by the door. The member of staff should notify other staff by using their alarm or other verbal methods; All broken key parts must be retained by the staff concerned and given to the Security Officer; All broken key parts must be disposed of securely by the Security Officer only; Any broken or damaged master key or salto fob must be reported to the Security Officer immediately for replacement and the damaged item returned to the Estates Department for repair/ replacement; Any broken or damaged key which is taken off the unit for repair by CWP Estates must be recorded onto the daily record sheet and the overall numbers amended by the Security Officer. e) Lost Pass keys Any missing/loss of a staff pass key or SALTO fob constitutes a major security breach for Low Secure Services and should be immediately reported to the nurse in charge/ shift coordinator (for further guidance refer to Potentially Dangerous Missing Items Flowchart. Appendix 7). Complete SUI Reporting Form (Appendix 12) f) Safe keeping of personal items No personal restricted or prohibited security items must be taken the clinical areas; Staff belongings must be secured into the designated appropriate lockers; Staff mobile phones must not be brought into the clinical areas and must be secured in staff lockers or stored securely off the unit. 3.4 Physical Security Alongside the plan and structure of the Low Secure Buildings and their perimeters, the following physical security procedures are in place to support and enhance safety for staff, patients and visitors; a) Closed Circuit Television To be read in conjunction with the Trust Surveillance System (CCTV) Policy (GR46) Soss Moss Low Secure Services are covered by internal CCTV cameras. These have been installed to support safe and efficient care, enhancing the validity of investigations and reducing the time that these investigations can take. These cameras are vision only and do not record sound. CCTV cameras cover communal areas only and do not cover any bedroom or bathroom areas to ensure the privacy and dignity of service users is respected. CCTV footage can only be reviewed by the following trained members of staff: Low Secure Services CSM, Modern Matron, Ward Managers, Deputy Ward Managers. CCTV can be reviewed to assist in finding missing items in the case where a ward lock down procedure has been implemented. In this instance if none of the above members of staff are available then the nursing team will contact 2 nd tier oncall who will provide the password for the CCTV. CCTV can be used as part of a post incident review to support the understanding of the incident and assist in developing any learning from this. This will be done in a controlled way and will first be reviewed independently by CCTV trained staff. Page 7 of 52

CCTV is NOT to be reviewed by any member of CWP staff if there are concerns that any criminal activity has taken place. In this instance any CCTV material will be handed over to the Police to inform their investigation. CCTV access can be regularly reviewed to ensure that no member of staff has accessed CCTV material without due cause. b) Use of DigiX Two Way Communication Radios (To be read in conjunction with Appendix 8 - Instructions for Use of DigiX Radio and Appendix 9 Quick Read Flow Chart Version.) Two way portable radios are provided to ensure efficient communication is maintained between clinical areas and with staff on escort duties throughout all times of the day. This is to ensure the safety and well- being of staff, service users and visitors to the Soss Moss site. Each clinical area is provided with a DigiX two way portable radio for use in: Non- standard emergency communication between clinical areas To maintain contact with other clinical areas when SAS alarms activated; TO INFORM IF CRISIS SUPPORT TEAM RESPONSE IS REQUIRED. It is the responsibility of the clinical area where the SAS alarm has been activated to contact other ward area(s) to inform if a Crisis Support Team response is required. Escorting duties on site but away from the main ward areas Escorting duties in the local area i.e. Local walks Fire evacuations (See fire procedure) Major incidents A mobile phone is also provided to ensure back up in respect of failure of unit telephone system and also for escorting duties into the community. The DigiX radio is not to be used when escorting service users in built up areas such as Alderley Edge due to the lack of privacy when communicating with the clinical areas. The Security officer checks that all radios and mobile phones are functioning at the commencement of each shift. Any defects are reported to the nurse in charge immediately. A radio check is completed between the escorting member of staff and the security officer prior to the radios being used for escorting purposes. Radio communication must be maintained between the escorting staff and the person responsible for Security duties. When in use, the radio must be carried on the person who is allocated to the role of security officer at all times. Radios must not be carried by the aerial but must instead be attached to the users waistband via the waist clip. Radios are used to transmit immediate security related information only. Professional standards of conduct are to be adhered to at all times. Only service users initials should be used to identify any individual being discussed over the radio. The security Officer ensures that a record is made of which outgoing radio ID number is allocated to which member of escorting staff. This is documented on the key, fob, radio and alarm sign out sheet (Current Security Policy Appendix 9. Leave record page 29 of 32) On return to the unit radios are stored in the airlock. They are not kept on the charger units as this will shorten the battery life, but are charged as necessary by security staff on the night shift. Maximum time on charge is 4 hours. Page 8 of 52

Whilst the Base unit is on charge the security officer on night duty will carry the emergency outgoing radio to maintain contact in the case of an emergency e.g. fire, Crisis Support Team response. Each clinical are will receive 1 Base unit radio, 2 outgoing radios and 1 emergency outgoing radio. Escorting members of staff will take one of the 2 outgoing radios with them on escort duties within the grounds, York House or on local walks. The emergency outgoing radio is solely for use in a major incident situation where the security officer has tuned their Base radio to Channel 4. In this instance, IF THERE IS A MEMBER OF STAFF OF ANY DISCIPLINE CURRENTLY USING AN OUTGOING RADIO the security officer will issue another member of staff with the emergency outgoing radio with the sole aim of maintaining contact with all outgoing radios ON THE USUAL WARD CHANNEL. At all other times this radio will be used by reception staff as a means of maintaining contact with the security officer 3.5. Transportation and CWP unit vehicles (refer to CWP Trust GR35 Safe Vehicular Transport of Service Users & Others Policy for further guidance) All unit staff who use any CWP vehicle to transport patients must ensure that they possess a valid driving license and are familiar with the vehicle prior to leaving the secure unit; All unit staff must ensure that they are physically able to drive a vehicle in accordance with provision stated in the Road Traffic Act (1988) legislation; Any Unit staff using their own vehicle for work purposes must ensure they have relevant business insurance as part of their personal car insurance. All patients require the appropriate S17 and risk assessment documentation to have been completed prior to being taken out in any vehicle. The risk assessment must have been completed by the MDT and have reference to number and gender of staff escorts required. The risk assessment must consider past history and any unpredictable behaviour. Providing a risk assessment has been considered and documented by the MDT a patient may be taken out by a single staff escort if this is considered safe. Any changes to mental state, presentation or risk since the time of the MDT risk assessment will be taken into account by the nurse in charge prior to the community leave going ahead. All patients must be risk assessed by the Nurse in Charge prior to being allowed in any vehicle to allow for dynamic updates to the risk assessment process. Unless there are specific risks documented in relation to patients travelling in vehicles then it would be usual for their escort status to be the same in a vehicle as for any other community based session. Keys for Unit vehicles are signed out via the TRAKA cabinet. Any incidents relating to the unit vehicles are reported immediately to the nurse in charge who will escalate this as necessary. Any concerns relating to the safety of the unit vehicles are reported to the security officer on shift and the nurse in charge who will ensure that the vehicle is not used by others until the safety concern has been resolved. Vehicle checks are completed weekly on a Sunday and the outcome of the checks documented on the Unit Vehicle Weekly Check Sheet (see Appendix 13) 3.6. Ward based security and restrictions The following security actions and restrictions are specific to low secure ward areas. a) Restricted Areas (High Risk) Restricted areas or high risk areas are defined as staff only areas or areas within the unit which by virtue of their degree of isolation or security risk patients must be supervised at all times. Page 9 of 52

Patients must not be allowed access into the following staff only areas under any circumstances, these areas will include: Staff offices; Staff toilets; Dispensary room when medicines are being dispensed. Patient access to these areas must be under staff supervision only: Unit airlock; Clinic room / dispensary / treatment room; Ward kitchen; Domestic / dirty utility room; Family visiting room York house; Gymnasium / therapies room b) Internal garden areas Doors to the internal garden area remain unlocked during daylight hours. It is the responsibility of the security Officer to ensure that all service users are accounted for and that the door to the internal courtyard is locked at dusk. The door can then be opened at the request of a patient providing it is safe to do so. In the event of a significant incident or disturbance the nurse in charge may take the decision to lock these doors, having first ensured all patients are accounted for inside. The doors should then be unlocked again once it has been deemed safe to do so. Patients who are on level 3 and 4 observations must be supervised in accordance with CWP policy; Therapeutic Observations CP25 c) Rehabilitation kitchen / Art room Sharp cooking knives and other specifically designated kitchen utensils are kept in the locked cupboard in the rehab kitchen and are used only under staff supervision; A list of all restricted items is kept in the kitchen restricted items drawer. It is the responsibility of the supervising staff to ensure that all security items are counted and recorded on commencement and completion of each therapy session; Any restricted items for use in the art room such as scissors are kept in the ward security cupboard and are signed out for each session as required by the security officer. d) Games room security items All games equipment must be secured and accounted for during any meal time period; All games equipment (snooker/pool cues and balls) must be accounted for by the supervising staff on commencement and completion of use; (Alderley Unit only) All games equipment must be secured on completion of use by the supervising staff member. e) Meal times One staff member will issue a full set of cutlery (knife, fork and spoon) to individual service users at the hatch and the staff will count them out and count them back in, filling the appropriate form kept within the kitchen area. ; Patients must not be allowed unsupervised access to any cutlery item; Staff must remain observant at meal times, if a service user wishes to leave the dining room/area during a meal time period, their cutlery must be handed in; Patients must not be permitted to leave the dining room area at the end of the meal until all cutlery has been returned and accounted for; Any discrepancy in the cutlery numbers must be reported immediately to the nurse in charge / shift coordinator and a lock down procedure implemented immediately. See also section 3.6 (i) Missing Restricted items. Page 10 of 52

f) Patient access to restricted items (Refer to Appendix 1 for a list of restricted and prohibited items) Patient access to any restricted item must only be during periods where safe management and observation by staff members can be facilitated. Access to restricted items during meal times, hand over periods or during security checks will not be able to be facilitated. Access to restricted items after 10.00p.m. and before 8.00a.m may not be able to be facilitated unless previously agreed with the nurse in charge / shift coordinator. g) Mobile phones Facilities staff will intermittently use an electronic device (mobile phone) as part of their work related role. When this is necessary the Facilities staff must only use the device within non inpatient areas; A unit mobile phone will be accessible from the security officer to any staff undertaking any community based external escort. This mobile phone must only be used to communicate clinical information and not for individual staff personal usage; CWP staff must not disclose personal mobile phone numbers or details to any patient or their relative / friend / visitor. Service User Access To Mobile Phones In order to support, promote and enable patients contact with their families and others, patients are allowed access to mobile phones within the following parameters; All patients will be provided with information with regards to the mobile phones that may be used within the unit and the protocols surrounding times of use. The mobile phone chosen will have no camera, internet access or recording facilities. Due to the local phone reception patients will be advised to purchase a Vodafone SIM as this may help access. Patients will be responsible for the purchasing of the phone and mobile top ups will only be purchased during community leave Provision will be made for patients to be provided with details of the mobile phones that are able to be used and where they can be obtained from. For those patients unable to leave the unit staff will arrange to collect phones on the service users behalf. The phones may be used on the unit between the hours of 10am and 10pm. The phones will be kept in the secure lockers between 10pm and 10am. Phones must not be used during meetings, ward rounds, group sessions or meal times. Patients mobile phones will be charged each night by the security officer and at other times if necessary and agreeable. All mobile phone chargers and leads will be kept with patients other restricted items and managed by the security officer. All service users will sign an agreement in relation to these conditions to ensure they are supported to understand the terms of use. (Refer to Appendix 10) Patients may take their phones out into the hospital grounds and out on community leave with them unless the care team have documented risk concerns in relation to this. In this instance access to the mobile phone will be care planned appropriately and in the least restrictive way. Any issues or concerns regarding phone usage will be addressed via care plans or intervention plans. h) Matches and lighters Access to matches or lighters within the clinical patient areas is not permitted for staff, patients or any other visitor. Any such items found within clinical areas will be disposed of. Refer to CWP Trust CP28 Nicotine Management Policy Page 11 of 52

The Trust operates a No Smoking protocol. Smoking is not permitted anywhere on site, this is without exception. Refer to CWP Trust CP28 Nicotine Management Policy i) Missing Restricted Items In the event of a missing restricted item refer to Appendix 7 Potentially dangerous missing items Flowchart. If the incident can be confidently and safely contained to one room and to the occupants within that room eg ward kitchen then assistance is sought to that room prior to any occupants leaving the room if the staff member considers it safe to do so. If there are valid concerns that a specific patient has secreted a restricted item then this patient should be managed on increased observations away from other patients as determined by the nurse in charge. 3.7 Personal searches. (To be read in conjunction with CWP Trust GR8 Security Policy - The Searching of Service Users and Environments) Routine searching of patients without justification or without due concern must not be undertaken at any time. Random or targeted searches of patients and their rooms must be carried out to promote safe environments or where information has been received which may indicate a certain patient(s) has been involved in any security breaches or incident. All patients must be appropriately dressed prior to entering day areas; this will promote privacy and dignity standards and also assist in maintaining safe environments. All searches of the low secure units are carried out to promote the safety of both staff and patients. When a search is deemed necessary in accordance with CWP policy; CP12 The Searching of Service Users and Environments & GR8 Security Policy) Staff who are directly involved in the search should be sensitive to their individuality and dignity. A comprehensive record of every search, including the reasons for it and details of any consequent risk assessment, should be made (MHA Code 16.14-16.27). The searching of patients must be undertaken as a consistent procedure; Two staff members must be present to conduct the search; one member to observe the other member conducts the search; Patients returning from any unauthorized leave (AWOL) must be subject to a pat down search or search with the hand held wand device and will include the removal of a patients shoes and outer clothing; Staff must record the search procedure using the record of searching form (Refer to Appendix 20); If a detained patient refuses consent to search, their responsible clinician or nominated deputy should be contacted without delay so that any clinical objection to searching by force may be raised. The patient should be kept separated and under close observation, while being informed of what is happening and why, in terms appropriate to their understanding. Searches should not be delayed if there is reason to think that the person is in possession of anything that may pose an immediate risk to their own safety or that of anyone else; Where a patient physically resists being personally searched, physical intervention should normally only proceed on the basis of a multi-disciplinary assessment, unless it is urgently required in order to maintain safety of all. A post-incident review should follow every search undertaken where consent has been withheld; Room searches must be undertaken when targeted searches of patients are conducted; Random searches of patients and their rooms must be conducted and recorded on the Record of search form (Refer to Appendix 20); Staff must not conduct a pat down search on any visitor. Page 12 of 52

Patient, Ward and Room Searches Where a patient refuses a personal search staff must report the issue to the nurse in charge/shift coordinator immediately; Where a patient refuses a personal search and staff know they have sufficient grounds to carry out a search without their consent staff and without the risk of injury to the patient or staff, the nurse in charge/shift coordinator must contact the Responsible Clinician to update them on the current situation and planned search; Where a patient refuses a personal search and staff know they have sufficient grounds to carry out a search without their consent staff and there is the risk of injury to the patient or staff, the nurse in charge/shift coordinator must contact the Responsible Clinician to update them on the current situation and inform the police; If there is concern that a patient may harm other patients and they themselves cannot be removed to a secure area then all other patients must be moved to a safe area. As far as is safe and practicable at least one member of staff undertaking the search will be the same gender as the service user to maintain dignity. All patient searches will be fully documented in the service users care notes and will follow CWP Trust CP12 The Searching of Patients Environment Policy 3.8 Unit lock down Following any breach of security, such as loss of keys, security door found open or loss of a restricted security item the nurse in charge/shift must immediately implement a lock down of the unit. A lock down will involve the securing of all access and control doors within the unit. No persons will be allowed to enter or exit the building during this operation unless agreed by the Bleepholder or Service Manager. This procedure will accomplish the control of all exits and persons and allow staff to carryout a systematic search of all areas. Immediately following the decision to implement lock down due to a missing restricted security item: The ward manager, Modern Matron, CSM must be notified by the nurse in charge/shift coordinator and given details of the incident; or 2 nd tier on call when out of hours All patients must be asked to assemble in day areas; All patients will be asked individually if they are aware of the whereabouts of the missing restricted item. A search of all environments (internal and external) including bins and food trolleys / containers will be undertaken. A review of CCTV will be undertaken by staff with CCTV access permissions; low secure services CSM, Modern Matron, ward managers and Deputy ward managers. If none of these staff are on duty then the CCTV review will be undertaken as soon as possible on their return to duty. If the search of the unit does not resolve the situation patients will be informed and may be asked to submit to a personal search; All personal searches must include removal of all patients shoes and outer garments, excluding the last layer; All searches must follow CWP Trust CP12 The Searching of Patients Environment Policy. If no success the Bleepholder / Service Manager must escalate to the next tier manager oncall. 3.9 Visitors to the unit a) CWP Estates / external contractors All contracted maintenance staff prior to attending the unit will have completed site working forms which identify all planned safe working procedures. As part of this procedure contracted maintenance staff will also be issued with ID badges by the Estates department. During an emergency situation this process will not be facilitated however due to the urgency of the unplanned event. Page 13 of 52

Prior to allowing CWP Estates or contracted maintenance staff into clinical areas the nurse in charge will ensure that the clinical area is safe for that maintenance work to be carried out; If the clinical area is not safe enough for CWP Estates or contracted maintenance staff to carry out planned work then a time and date must be agreed for them to return. CWP Estates must be contacted where this affects planned or essential maintenance work; All Estates personnel and / or external contractors will be issued with small tool box by the Estates department which will be used to prioritise the tools / equipment needed to carryout the work required; On arrival at either Alderley or Saddlebridge CWP estates or contracted maintenance staff will discuss their requirements with the security officer. If it has been agreed that the work can be safely undertaken they will be issued with an SAS alarm prior to entering the clinical areas. Once inside the inpatient areas the Estates personnel and external contractors will be accountable for the safe keeping of any tools/ equipment and act in a manner that will not compromise security; If the Estates personnel and external contractors report any items missing then the nurse in charge / shift co-ordinator must implement the Potentially Dangerous Missing Items Flowchart (Refer to Appendix 7); During any incident which may involve clinical safety the estates personnel and / or external contractors will be asked to ensure all tools are accounted for and will be asked to leave and be escorted by unit staff to a safe area. Arrangements must be made regarding future visit to complete works; All breaches in security by CWP Estates staff and / or external contractors will be documented and reported to the nurse in charge / shift co-ordinator, Estates Lead action taken in discussion with the unit manager; If CWP Estates or contracted maintenance have any concerns regarding clinical safety they must raise their concerns with the nurse in charge / shift coordinator immediately. b) Visiting professionals This includes medical staff, social workers, health professionals and legal representatives and all visitors to the unit: All visiting professionals must not bring restricted security items into the clinical area; All visiting professionals must be given as a minimum an alarm fob by the security nurse upon entering the unit which must then be returned when they leave; This is not required if the visiting professional is attending a CPA meeting and will not be spending any time on the unit or alone with the patient. All professionals must ensure that they discuss the circumstances of their visit and any support required with the Security Officer so that this can be assessed and where possible agreed; Security Officer or nurse in charge must ensure that visiting professionals are aware of any changes in a patients behaviour / risk factors prior to their visit; Visiting professionals must be escorted within the unit by staff for the duration of their visit unless agreed with the nurse in charge; Visiting professionals must not be issued a master key or salto fob. If private time with service users is requested this must be discussed and agreed with the nurse in charge / shift coordinator. c) Visits by family and friends As part of the admission process the unit social worker will discuss the visiting process with patients and their family / carers as appropriate. Page 14 of 52

All visitors names and if possible contact numbers will be entered into visitors log book following discussion with patients regarding who they want to visit them eg family members and friends. Log books are kept in the airlock and checked by security when visits commence. The unit Social Worker and named nurse will advise all visitors to book visits in advance with the social worker or nursing staff which will ensure the visitor s room is available for the preferred day and time of visit. This will ensure the patients and their visitors will have quality private time together. All visits will normally be facilitated in the family room on each ward; All visiting family and / or friends must be reminded not bring restricted security items into the clinical area; This will be done by the Unit social work for each initial visit and repeated as required thereafter. All visitors will be provided with a secure locker or area in which to store restricted or prohibited items if they access the clinical inpatient areas; d) Observation during visits by family and friends All visitors will be escorted and supervised by a member of staff at all times whilst accessing the clinical inpatient areas. During the visit staff will/may observe the visit, either from the observation window on the Alderley Unit or outside the door of the visitor s room at Saddlebridge. Observation levels are pre-planned by the MDT and discussed with Ward managers and/or nurse in charge on the day. Staff will continue to remain vigilant regarding the visit when observing from outside of the room. Observing staff must be vigilant during supervised visits, especially where physical contact is made between the patient and their visitor; Visitors are encouraged to discuss any issues they have with the Unit Social Worker, Ward Manager or nurse in charge prior to the visit, or immediately following the visit if issues have arisen during the visit. Termination of a visit by family and friends must only be undertaken as a last resort where there is an unmanageable risk of harm present; If during any visit by family or friends there is a risk of harm to patients or staff, staff must notify the Police as a matter of urgency; If there are any risks to the safety of any visitor during any visit, staff must act accordingly and take action to safe guard all persons; If any visitor is witnessed or suspected of using verbal abuse or any other abuse towards staff or patients this must be acted on appropriately and the consequences of using such behaviour in accordance with CWP Trust Policy CP6 The Management of Violence & Aggression A pat down search of the patient must be undertaken immediately following a supervised visit where there are concerns regarding concealment of restricted or illicit substances; All restricted items brought in by family and friend s visits intended for a patient must be handed to staff for checking and documenting into unit records. e) Visits by children (young persons under 18 years of age) In support of this policy and for further reference on children visiting CWP inpatient areas refer to CWP Policy CP9 The Visiting of Patients by Children on Inpatient Areas. The Mental Health Act (1983) Code of Practice 1999, 26.3 states: A visit by a child should only take place following a decision that such a visit would be in the child s best interests. Decisions to allow such visits must be discussed and agreed by the MDT prior to the visit taking place. Both Alderley Unit and Saddlebridge Recovery Centre adhere to strict guidelines when allowing Page 15 of 52

visits to the units, and work on the principal that The Welfare of the child is paramount and must override all other considerations. No children (under the age of 18) will be allowed to visit the Saddlebridge or Alderley units except for the following circumstances: Where it is identified that the patient has parental responsibility and / or a significant relationship, in which it is in the child s interest to maintain contact. This must be discussed and agreed through the MDT; a relevant risk assessment will be completed to ensure that all relevant risks have been considered. It is the responsibility of the MDT, lead by the Ward Social Worker to ascertain if the child who is visiting the unit is involved in any current or previous child protection issues or has any involvement with Social Workers from Children s Social Services and if so liaise accordingly. The Ward Social Worker will discuss with families involved with the child all issues relating to the visiting procedures and what support is expected from families when the child visits. This is in relation to the child s supervision, safety and physical and emotional wellbeing during the visit. If any special arrangements are to be made to support the visit they are discussed between the Ward Social Worker and the family and put into place before the visit takes place. Once all of the above information has been gathered and the MDT have documented their support of the visit a CV1 Child Visiting form must be completed as per CWP Trust Policy CP9 The Visiting of Patients by Children on Inpatient Areas. It is the responsibility of the Ward Social Worker to ensure that this has been completed. Notification must be given to the Safeguarding Team by the ward Social Worker for all individual visits. Where a child visit is permitted the visit must only be undertaken in a designated room; the family visiting room which is provided away from the main ward area, restricting contact with other service users on the unit. There will be CWP escorting staff in attendance throughout the visit. f) Patient visitors and prohibited and restricted Items For reasons of safety and security, items that can present a hazard or breech essential security need to be controlled. A list of prohibited and restricted items will be posted at the entrance to the unit (Refer to Appendix 1). This must be brought to the attention of visitors and they will be asked to hand over any items before entering the unit. When unit staff receive intelligence that a visitor maybe attempting to bring in a prohibited or restricted item, the visitor must be contacted by the Ward Manager and reminded of the visiting and restricted items policy prior to any planned visit; Low secure staff when they suspect or know that there may be prohibited or restricted items being brought into the unit must ask the visitor to agree to declare the contents of the package / bags; If the visitor refuses to comply with a request to declare the contents of their bags then access to the visit must be denied; Any decision to deny access to a visitor must be reported to the ward manager, Modern Matron or CSM, or out of hours to the 1 st tier oncall / Bleepholder covering CWP East, and a short term plan of action agreed or until the MDT can discuss the incident further. If staff suspect that prohibited or restricted item has not been declared: When low secure staff suspect or know that a prohibited or restricted items has not been declared by a visitor that person must not be allowed access to the patient. The Nurse in Charge/ shift co-ordinator must be informed immediately; Page 16 of 52