The Newcastle upon Tyne Hospitals NHS Foundation Trust Key Control Operational Policy Version.: 1.0 Effective From: 18 January 2016 Expiry Date: 18 January 2019 Date Ratified: 22 December 2015 Ratified By: Estates and Facilities Management Team 1 Introduction 1.1 This policy outlines key control measures, which are designed to ensure the security of the Trust, and will take in to account the Trusts Health and safety regulations. 1.2 Although hospital areas need to be accessible 24 hours a day, it is advisable that doors other than those doors essential to the normal routine running of the hospital, are locked, (subject to Fire and Health & Safety regulations). 1.3 Health Centers and Clinics throughout the Trust, and other Trust sites such as the Centre for Aging and Vitality (CAV) and The Centre for Life must also adhere to the policy 1.4 The Royal Victoria Infirmary (RVI), Freeman, and Trust areas of the CAV are divided into a number of areas, each of which has been allocated its own suite of keys. The Chief Executive retains the Grandmaster keys for all sites. 1.5 Failure to adhere to the policy could result in disciplinary action being taken. 2 Scope 2.1 This policy is relevant to all Trust employees. 2.2 Please note this policy does not apply to any cupboard keys. These can be ordered through either Estates or Supplies departments. For information on the procedures for obtaining drug cupboard keys please refer to the Medicines policy. Page 1 of 10
3 Aims 3.1 To ensure the security and safety of the staff, patients and visitors to Trust premises. 3.2 To ensure the security of the Trust premises and property. 4 Duties (Roles and Responsibilities) The Assistant to the Chairman and the Chief Executive handles all requests for new keys for the RVI and Freeman Hospital sites. For other Trust properties it sits with the site manager. The Directorate Managers/Department Heads are responsible for the implementation and operation of a robust system of key control All Trust staff are responsible for any keys for trust property that are in their care. 5 Policy Description 5.1 Categorisation To ensure the security of the Trust keys they must be allocated to staff in the following four categories. Category 1 Individual keys: giving access to a particular area / room. These will be issued to the prime users i.e. a member of staff working alone in an office on a regular basis, or the Office Manager. Any requests for keys (excluding cupboards and drug cupboard keys) need to be made through the Estates helpdesk. Category 2 Departmental keys: giving access to specific sections of the Trust. These will be allocated to departmental heads, their deputies or nominees if necessary. Category 3 General keys: giving access to all areas of Trust buildings but not external doors. These will only be issued to staff who require access throughout Trust buildings. Category 4 External access keys: giving access to the building from outside and will be allocated only to staff, who are required to open and close buildings or parts thereof. Page 2 of 10
5.2 Accountability 5.2.1 Keys, which access buildings or other areas of Trust property, are and remain the property of the Trust. 5.2.2 Keys to departmental key cabinets and keys therein are the responsibility of the ward or departmental manager. Spare keys to the key cabinets should be held by the Directorate Manager / Departmental Head. 5.2.3 Directorate Managers/Department Heads are responsible for the maintenance of lists of key holders, and areas for which specific keys are allocated. These lists should be up dated regularly. 5.2.4 A list of the locations of key cabinets/ key presses within directorates / departments, along with a list of the keys located inside these cabinets should be forwarded to the Directorate / Departmental Manager. These lists should then be forwarded to the Portering / Security Services Manager and Patient Services on the respective site. 5.2.5 Directorate Managers/Department Heads are responsible for the implementation and operation of a robust system of key control and the implementing of a system for the collection of keys from staff who leave the Trust, or transfer to other departments. 5.2.6 Keys to areas with restricted access i.e. plant rooms, service areas and roofs, are controlled by the Trust s Estates Department, Healthcare Support (in the PFI buildings) and the Chief Executive. 5.2.7 Sub-master keys for areas with suited locks will only be issued to senior members of staff, or in the event of fire alarm activation to members of the Trusts Fire Response Teams. These keys are available from: Freeman main reception Security at the RVI Leazes Wing reception Security at the CAV. 5.2.8 Keys for staff accommodation are controlled by: Hotel Services on the RVI site for Grainger Park Road. HR Medical Staffing for all on-call rooms. Page 3 of 10
Hotel Services also hold keys to allow access for cleaning purposes out of hours. 5.2.9 Keys for relatives accommodation (Beechwood) are obtained through: Wards: 23, 38, 12, NCCC Radiotherapy, Transplant coordinators on the Freeman site. Leazes reception at the RVI. Keys are allocated to relatives by the Wards or Patient Services. 5.2.10 Ward drug cupboard keys are held by the senior nurse on the ward / department. Spare sets of drug cupboard keys are held in secure key cabinets, by the Patient Services Coordinators on the RVI and Freeman sites, and by the Security Department on the CAV site. Only senior members of staff will be allocated these keys, on authority of the ward or departmental manager. Refer to the Trust Medicines policy for more detail. 5.2.11 High-risk keys such as those for Pharmacy and Cashiers areas are not retained in the normal key control system, but are the responsibility of the respective departmental head. Access to the Pharmacy areas cannot be gained out of hours other than contacting a member of the on-call pharmacy staff. Keys for emergency drugs cupboards are held at the Main reception level 2 Freeman, and are available to authorised personnel only. Cashiers Offices on all sites cannot be accessed other than by contacting the respective on-call member of staff. 5.3 Lost/stolen keys 5.3.1 As soon as a key is confirmed to be lost / stolen it should be reported to the Directorate / Departmental Manager and the Security Department. 5.3.2 An investigation will then take place by the ward / departmental manager to ascertain whether or not a replacement key can be issued or a new lock should be fitted and new keys supplied. If there is any uncertainty security can be contacted for advice. If a suite of keys needs to be replaced then the Directorate/ Department may be charged the cost of replacement. 5.3.3 For drug cupboard keys please refer to the Trust Medicines policy. Page 4 of 10
6 Requests for additional/ replacement keys 6.1 The responsibility for the authorisation of additional / replacement keys at the Freeman Hospital, the RVI and CAV sites lies with the Assistant to the Chairman and the Chief Executive. Key requests for the Freeman, the RVI and CAV sites must be made through the Estates helpdesk. The decision to replace keys in Health Centre s, Clinics and Trust sites such as The Dental Hospital, The Centre for Life and CAV lies with the Site/ Unit Managers. 6.2 Requests for keys at the Freeman, the RVI and CAV sites will be added to a database held by the Estates Helpdesk. 6.3 Following a request a decision will be made as to the allocation of the replacement / additional key. The key information will then be forwarded to the Estates Department for replacement via the Trust Estates Department through the correct replacement systems i.e. the Estates Department will cut a key on site or replace the key via an approved key supplier to the Trust 6.4 Members of staff must not purchase keys via external means which are not approved by the Trust. This would be a disciplinary offence. 6.5 Where locks are changed only one key must be issued to the users. It is the responsibility of the Estates staff/ Interserve to provide the following information to the Estates helpdesk when a lock has been changed:- Building no, level, room number and who the keys have been issued to (staff ID must be checked before issuing the key) Any additional keys for the lock must be delivered to the estates helpdesk. Estates helpdesk will then issue a key for the lock to Security and/or Patient Services (if required) If any additional keys are required by the users they need to be requested in the usual manner. 6.6 Key storage 6.6.1 It is recommended that where possible departmental and offices keys are stored and issued from a main hospital reception area. If this is not appropriate then departments may use key cupboards for their own keys, these should always be kept locked when not in use. 6.6.2 Keys which are issued from reception areas / taken out of key cabinets must be strictly controlled, by signing in/ out of a register. The register should include the following information: date, time signed out, time returned, who has signed it out and their contact number/ information. It Page 5 of 10
is the responsibility of the staff member on the reception / with the key cabinet to ensure the register is completed and is legible. 6.6.3 Keys must returned the same day to their point of origin, unless special arrangements have been made with the relevant persons. 6.6.4 Keys must not be held in desk draws, or left unattended. Keys should always be locked away in a Trust standard key cupboard when not in use. 6.6.5 A standard key cupboard must always be used for the storage of keys 6.6.6 The key cupboard must be metal in design and lockable, and must have sufficient capacity to hold all keys stored within. Keys should not lie in bottoms of these key cabinets but should have an allocated hook and be correctly tagged and logged. 6.6.7 A member of the Estates staff will affix the standard key cupboard to a solid wall on request. 6.6.8 Spare keys for key cupboards will be held by the Directorate / Departmental Manager. 6.6.9 Each key cabinet must have a comprehensive list (which must be updated regularly when keys are added or taken away permanently) detailing the areas specific keys stored within that key cabinet gives access to i.e. Key Location 1 Staff room 6.7 Key control measures 6.7.1 The system of key suiting (where applicable) will be adhered to. Keys will be suited taking into account department, floor area or building. 6.7.2 The Trust Estates Department will control the system of key suiting across the Trust. 6.7.3 A register should be kept by the key cupboard. When keys are taken from their key cabinet they must be signed out and when returned must also be signed back in. 6.7.4 Keys should never be left in locks. 6.7.5 Key control measures must be strictly adhered to, and should only be issued against a signature and a legible name. Page 6 of 10
6.7.6 The room or area for which the key / keys is designated must not be identified on a fob, or any other attachment to the key. 6.8 Access out of hours 6.8.1 The issuing of keys overnight from departmental key cabinets is not acceptable practice, unless there has been a Directive from the Directorate/ Departmental manager. 6.8.2 Access to areas locked out of hours should be via Trust security staff. 6.8.3 When access is given to specific areas a written report must be submitted to the department head detailing date, time, the name of person requesting access and the name of the security staff member allowing access. 6.9 Site Specific 6.9.1 The Dental Hospital Access to keys The Dental Services Directorate, Dental Hospital Reception and Hotel Services Department, hold keys for the offices / departments in the Dental Hospital. A key register must be used and maintained by each of these areas. This building s locks are not suited, therefore no sub-master keys are available. 6.9.2 The CAV site Access to keys Site security holds keys which are issued on a daily basis to authorised users. Site security holds keys for access to all areas of the site. 6.9.3 Centre for Life Access to keys Master keys for site, are held by the Centre for life (CLF) and University management teams (Head of Department and Institute Manager), in a secure key cabinet. Strict controls on the use of these keys are in place. Office staff are issued keys for their own department /office or area of work. Requests for additional or replacement keys Responsibility for the authorisation of replacement / additional keys at CFL lies with the Section Heads with in the departments. Page 7 of 10
7 Requests for new door locks/removal of existing Requests for new door locks of any type (digital, keys, swipe card, bathroom) should be requested via the Trust White Form System and must have an approved Security Risk Assessment endorsing the request. Security risk assessments should be requested by the Security lead on the relevant site. Requests for removal of locks of any type (digital, keys, swipe card, bathroom) should be requested via the Trust Estates Helpdesk and must have an approved Security Risk Assessment endorsing the request. Completed Security Risk Assessments should be emailed to the Building Workshop Manager on the relevant site quoting your unique helpdesk reference number. Estates will ensure all remedial work and making good is completed as part of the helpdesk call. 8 Training ne required 9 Equality and diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed. Page 8 of 10
10 Monitoring compliance Standard / process / issue Monitoring and audit Method By Committee Frequency Key requests Have to meet the agreed criteria (included in the body of this policy) before keys are agreed. Records are kept of key requests on both sites, these are monitored for : The Assistant to the Chief Executive Ongoing Frequency of requests Issues (keys breaking) Other patterns Lost Keys Before any action is taken the loss is investigated and it is assessed whether the key can be replaced or the lock/ suite of locks needs changing. This will be reported back to the Assistant to the Chief Executive (security will give advice where necessary) The Directorate Manager/ Matron of the relevant department Ongoing 11 Consultation and review This policy document has been written by the Head of Portering and Security, the Capital and Planning Officer and developed through meetings involving the following people: The Assistant to the Chief Executive The Director of Transforming Newcastle Hospitals The Chief Building officer Matron Patient services The following staff were also consulted: The Head of Nursing for the RVI The Assistant Director of Pharmacy The CAD support officer 12 Implementation On release this policy will be highlighted to the following groups: The Matrons Forum Page 9 of 10
The Sisters Forum The Directorate Managers meeting The policy will be highlighted in the Trust newsletter. The policy will be included in the Trust Policy Directory. 13 Associated documents Medicines policy Page 10 of 10
The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. PART 1 1. Assessment Date: 22.12.2015 2. Name of policy / strategy / service: Key Control Operational Policy 3. Name and designation of Author: Samantha Grainger, Estates Officer & Mick Brannen, Portering & Security Manager. 4. Names & designations of those involved in the impact analysis screening process: Samantha Grainger, Estates Officer, Rob Sanderson, Chief Building Officer 5. Is this a: Policy X Strategy Service Is this: New X Revised Who is affected Employees X Service Users X Wider Community 6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and pasted from your policy) This policy outlines key control measures, which are designed to ensure the security of the Trust, and will take in to account the Trusts Health and safety regulations. 7. Does this policy, strategy, or service have any equality implications? Yes X If, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons:
8. Summary of evidence related to protected characteristics Protected Characteristic Race / Ethnic origin (including gypsies and travellers) Sex (male/ female) Religion and Belief Sexual orientation including lesbian, gay and bisexual people Age Disability learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section Gender Re-assignment Marriage and Civil Partnership Maternity / Pregnancy Evidence, i.e. What evidence do you have that the Trust is meeting the needs of people in various protected Groups This policy does not differentiate race or ethnic origin This policy does not differentiate between male and female This policy does not differentiate between religions and beliefs This policy does not differentiate between sexual orientation This policy does not differentiate between age This policy does not differentiate against any disability; all individuals involved in working on ventilation systems must be appropriately qualified or supervised. This policy does not differentiate against gender re-assignment This policy does not differentiate on this This policy does not differentiate on this Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date) Does the evidence highlight any areas to advance opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date) 9. Are there any gaps in the evidence outlined above? If yes how will these be rectified? 10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer. Do you require further engagement? Yes X
11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and family life, the right to a fair hearing and the right to education? PART 2 Name: Samantha Grainger Date of completion: 22.12.2015 (If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)