SH NCP 64 LOCKDOWN POLICY Version: 1 Summary: Keywords (minimum of 5): (To assist policy search engine) Lockdown is the process of controlling the movement, access and egress of people around NHS property in response to an identified risk, threat or hazard that might impact on the safety and security of people and assets as well as the capacity of the that facility to continue to operate and should be read in conjunction with the trust HAZMAT Policy and trust Security Management Procedure. Lockdown, control of movement, access, safety, security Target Audience: All staff employed by Southern Health NHS Foundation Trust Next Review Date: May 2019 Approved & Ratified by: Health & Safety Forum Date of meeting: 27 April 2015 Date issued: Author: Sponsors: Nigel Dowland - Local Security Management Specialist Mark Brooks Director of Finance (Security Management Director) Fiona Richey Head of Risk & Business Continuity Dave White Head of Health & Safety, Fire and Security 1
Version Control Change Record Date Author Version Page Reason for Change Nov 2014 Nigel Dowland 1 New Trust Policy Feb 2015 Nigel Dowland 1 1, 3, 4, Addition of Appendices 33-40 16.02.2016 1 Review date extended for 3 years (from May 2016 to May 2019) Reviewers/contributors Name Position Version Reviewed & Date Dave White Head of H&S, Fire Safety & Security Fiona Richey Head of Risk & Business Continuity Mark Brooks Director of Finance (SMD) Jeremy Smith Associate Director of Estates & Facilities Management Stuart Brown Temporary Emergency Planning Officer v0.1-08 Dec 14 Alan Johnstone Head of Estates and Capital Darren Hedges Health & Safety Adviser SHFT 2
CONTENTS Page 1. Introduction 4 2. Purpose 4 3. Scope 4 3.1 Definitions/Abbreviations 5 4. Duties & Responsibilities 5 5. Procedure / Implementation 6 5.1 Types of Lockdown 6 5.2 Partial Lockdown 6 5.3 Progressive Lockdown 7 5.4 Full Lockdown 7 5.5 Who Can Implement a Lockdown? 7 5.6 Controlling Access / Egress 7 5.7 Guidance on Developing Plans for Lockdown 7 5.7.1 Identification of Local Stakeholders 8 5.7.2 Site Profile 8 5.7.3 Building Profile 8 5.7.4 Refuge 10 5.7.5 Lockdown Procedure Checklist 9 5.7.6 Lockdown Action Card 9 5.8 Creation of the lockdown procedures 9 6 6.1 Training Requirements 9 6.2 Legal Framework 10 7 Monitoring Compliance 10 8 Policy Review 11 9 Associated Documents 11 10 Supporting References 11 Appendices App A Site Profile 12 App B Building Profile 13 App B1 Security Profile 14 App C Lockdown Procedure 15 App D Lockdown Action Card 1 16 App E Lockdown Action Card 2 17 App F Lockdown Action Card 3 18 App G Lockdown Action Card 4 19 App H List of Critical Sites 20 App I Lockdown / Hazmat Risk Assessment form 22 App J Equality Impact Assessment 28 3
LOCKDOWN POLICY 1. INTRODUCTION 1.1 Lockdown is the process of controlling the movement, access and egress of people around NHS property or other specific buildings / areas in response to an identified risk, threat or hazard that might impact on the safety and security of people and assets or, in deed the capacity of that facility to continue to operate. 1.2 Southern Health NHS Foundation Trust is required to provide a safe and secure environment in which patients, staff and visitors may safely engage in a therapeutic regime. A lockdown may be implemented by the Trust as part of a security incident or the major incident plan. This may be in partnership with other organisations both NHS and external e.g. Police intelligence. 1.3 Local managers may also need to be able to lockdown their own area e.g. in the event of a missing patient or a possible incident of violence and aggression in a community clinic where the manager decides to lockdown the area so other patients or service users can t be affected. The capability of NHS Trusts to lockdown their site or buildings fits in with their statutory responsibilities as Category One Responders as defined by the Civil Contingencies Act 2004 1.4 This policy has been written with reference to the Mental Health Act (1983 as amended 2007); The Mental Health Act Code of Practice (1999 as amended 2008) and the Human Rights Act (1998). 1.5 This policy applies to all in-patient units and should be read in conjunction with the trust Hazardous Material (Hazmat) Policy, Security Management Procedure (SH NCP 22) and Health & Safety Policy (SH HS 04), Risk Management Policy (SH NCP 25) 2. PURPOSE The purpose of this policy is to provide guidance to managers and staff that will enable them to follow appropriate steps to achieve a lockdown of the site that they manage / occupy. It is to work alongside the Incident Response Plan and other emergency plans / continuity plans, but may be used as a standalone policy if required. It is important to remember that many sites / buildings have multi-occupancy arrangements and SHFT plans must fit with any overarching lockdown plan that may be in place. 3. SCOPE The policy applies to all SHFT critical sites listed at Appendix H. It requires all managers of such areas, buildings or sites to work with security management staff to prepare a process whereby the area, building or site can be locked down when required. This may require collaborative working with other agencies or organisations i.e. local Police intelligence teams and /or Special Branch. 4
This policy is to be read in conjunction with the SHFT Security Management Procedure, Hazardous Material Policy (HAZMAT) and the SHFT Standard Operating Procedures for Ebola Identification. 3.1 DEFINITIONS / ABBREVIATIONS SHFT Southern Health NHS Foundation Trust CBRN Chemical, Biological, Radioactive or Nuclear (Incident) LSMS Local Security Management Specialist SMD Security Management Director MHA Mental Health Act 1983 MCA Mental Capacity Act 2005 CQC Care Quality Commission IRP Incident Response Plan 4. DUTIES & RESPONSIBILITIES 4.1 The Chief Executive has overall responsibility for ensuring the trust has a lockdown policy in place in accordance with the criteria set by the Quality Care Commission (CQC). 4.2 The Security Management Director (SMD) is presently the Director of Finance with responsibility for security management within the trust. The SMD is responsible for providing, where reasonably practicable, a safe and secure working environment and ensuring the safety and security of employees, patients, service users and others. 4.3 The Local Security Management Specialist (LSMS) is responsible for: The development of this policy, following guidance from NHS Protect. Providing guidance over the characteristics that will influence the ability of any site to effectively lockdown and the resources required to do so. Support site teams with the development of their lockdown processes and procedures. Support the undertaking a lockdown when required. Support inter-agency collaboration. 4.4 The Estates Team will lead on issues relating to the functionality of buildings and building resilience. They will have an in-depth knowledge of the structure and various systems that operate within any building. Their knowledge will be invaluable when determining whether it is possible to achieve a full or partial lockdown. 4.5 The Emergency Preparedness, Resilience and Response (EPRR) Working Group is responsible for the development of the Trust Incident Response Plan which documents plans and advice on preparing for specific types of disaster and/or attacks. 4.6 The Trust Communications and Engagement Team will help to ensure that a controlled message is broadcast to staff, patients and visitors within the trust and to the outside world, informing them of the current situation. The local media can be very helpful in directing people away from a site or building. The Trust Communications and Engagement Team will be able to seek their assistance, so it is important that they are involved and kept up to date as the situation develops. 5
4.7 All Directors, Operational Managers, Service Managers and Departmental Managers are accountable for ensuring that: They work with their teams, estates representatives, and the LSMS to identify and document the critical assets within the site, Develop a lockdown profile for their site/department, taking into consideration local circumstances and the NHS services provided. Managers must keep in mind that if there is a change to the services provided at a site, the lockdown plan must be reviewed to ensure that it reflects the new situation, Determine if a lockdown (partial or otherwise) is achievable, Identify appropriate resources to undertake a lockdown, Identify and disseminate a single point of contact and a backup, for notification of a requirement to activate lockdown plans, In consultation with local Stakeholders, develop a lockdown plan, Share details of the agreed lockdown plan with their teams to ensure that if, or when implemented, all staff are aware of their role and responsibility, Maintain the lockdown plan with the local Incident Response Plan / Business Continuity Plans and forward a copy to both the LSMS and the Trust Risk and Resilience Officer. That plans are tested for robustness and appropriate amendments or revisions are cascaded. 4.8 All Staff have a responsibility to take reasonable care of their own safety and security as well as the safety and security of others and to participate as required in the event of the implementation of a lockdown. In order to support a lockdown, staff will be assigned relevant activities to support lockdown procedures. Staff will report to their manager, situations where exposure to any security or infection hazard / threat may give cause for concern so that investigation and appropriate action can be undertaken. 5. PROCEDURE / IMPLEMENTATION 5.1 Types of Lockdown In locking down a facility, there are three key elements; preventing the entry, exit and movement of people on a trust site, part of a trust building or in a building or site where NHS services are provided. In preventing the entry, exit or movement of people, or a mixture of the three, the overarching aim of implementing a lockdown is to either exclude or contain staff, patients and visitors. A lockdown may be either, partial, progressive or full. All visitors should be requested to follow directions to support a lockdown; however, it is noted that the containment of any person against their will is prohibited. 5.2 Partial Lockdown (Static or Portable) A partial lockdown is the locking down of a specific building or part of a building. The decision to implement a partial lockdown will usually be in response to an incident. This response will help to ensure that identified critical assets such as personnel and property are protected. A partial lockdown can be static or part of a portable lockdown whereby an ongoing lockdown is moved from one location to another. 6
5.3 Progressive Lockdown A progressive or incremental lockdown can be a step-by-step lockdown of a site or building in response to an escalating scenario. 5.4 Full Lockdown A full lockdown is the process of preventing freedom of entry to an exit from either an entire NHS trust site; specific NHS building or premises that offer NHS services. In order to ensure a safe and secure environment it is essential that all relevant stakeholders engage in the development of a robust action plan. 5.5 Who Can Implement a Lockdown? By its very nature, a lockdown should be considered in a variety of situations, many of which require an immediate implementation and others which are in response to a major incident. It is clear that if an incident is occurring outside a premise, the senior member of staff in the premise should have the authority to make a decision to lock the premise as an immediate response to protect patients, staff and property (assets). Equally, the lockdown can be called by the Duty Manager as part of the Trust Incident Response Plan in response to a larger or impending risk. Any lockdown will involve reporting to the Duty On-Call Senior Manager / On-Call Director and it is this person who decides if the lockdown should continue and when it is to end. 5.6 Controlling Access / Egress in the Event of a Lockdown When following assigned duties in the event of a lockdown, all employees must remember that because all heath care sites and buildings are usually open to the public, members of the public have an implied licence to enter them. However, the owner of any such premises has the right to refuse access when required. 5.6.1 While NHS professionals can give direction within their premises (e.g. stating which exit someone can use), it is unlawful to forcibly prevent exit from NHS premises, with the exception of service users legally detained under the MHA. Nonetheless, there may be circumstances when a lockdown from existing NHS premises (or part of them) is desirable. If this occurs, MHS staff can only appeal to individuals to stay in the site and/or building identified for lockdown. If individuals choose to leave, then a safe route must be available for them to do so, with the exception of service users legally detained. 5.7 Guidance on Developing Plans for Lockdown Creating a lockdown procedure is a four step process: i. Complete the Building Profile this will help you assess the risks that are present and the complexities of locking the building down. ii. Choose the appropriate lockdown action card the lockdown action card is an aide memoire for your staff to use if a lockdown is required. It sits with the Incident Response Plan Action Cards and works with them. iii. Communicate with all staff all staff should be aware of what is needed when a lockdown is required. This should be discussed at team meetings and regularly updated. 7
iv. Practice At least once every 5 years, a full lockdown practice should be completed to ensure that the plan works and staff are aware of their duties. Responsible persons are to keep a hard copy of the floor plans of their sites and buildings along with their copy of the Trust Incident Response Plan (IRP). E. copies of these plans and photographs are available at: G:\FM SHARED UNRESTRICTED CONTROL\Critical Site Plans By using the appendices that accompany this policy, the manager of each site, in conjunction with the Trust LSMS / Security Advisor, will be able to develop a lockdown procedure for the site or premise. Each premise will have a lockdown procedure created and these will be reviewed by the site manager at least every 5 years or sooner as required by organisational changes. 5.7.1 Identification of Local Stakeholders Stakeholders in this context are the people / organisations who will be either instrumental in establishing an effective lockdown, or affected by the implementation of a lockdown. These stakeholders must be included in the planning process at some point. 5.7.2 Site Profile (Appendix A) Develop a Site Profile, taking into account the physical geography of the healthcare site for example: The size of the site, Marking out its perimeter, Access and egress points, The location and route of communications and the number of buildings on the site, Up to date site maps, Up to date site maps, floor plans and aerial maps, in conjunction with a live walk through should facilitate the development of this profile. This should be done in conjunction with a member of the estates team, hospital manager and, where required, the LSMS. 5.7.3 Building Profile (Appendix B) Create a building profile to review the functionality and capability of the buildings to lockdown either fully, partially or progressively. This will include: A full inventory of doors and windows, The amount of glazing and ability to resist a blast or forced entry, The ability to control access either manually or automatically, The building shape, height and condition for surviving a blast Whether it has air conditioning throughout which could spread a contaminant, Where power supplies are housed. 8
5.7.4 Refuge As part of the assessment, a room should be identified which has a telephone, is lockable and ideally has minimal windows. This will be the safest area in the event of a major assault against the building. Although unlikely, it is preferable to have identified this room prior to it being required. 5.7.5 Lockdown Procedure Checklist (Appendix C) The lockdown procedure checklist is an aide memoire to ensure that the person creating the procedure has considered all aspects that may be required. If after completing the checklist, any aspect has a NO answer, then this should be rectified and the checklist completed again until the answer is YES. 5.7.6 Lockdown Action Card (Appendix D G) Using all available information gained from the assessments detailed above, the manager will choose the most appropriate action card from the four choses: Lockdown Action Card 1 (Appendix D) Suitable for a building where trust staff are the only occupier and are fully responsible for the building. Lockdown Action Card 2 (Appendix E) Suitable for a building which has multiple different occupants / teams, but is predominantly controlled by trust staff. This requires agreement amongst all occupants. Lockdown Action Card 3 (Appendix F) Suitable for areas which are controlled by one manager, but involve multiple buildings or a large building with multiple, separate areas within. Lockdown Action Card 4 (Appendix G) Suitable for buildings / areas where trust staff are not the controller for the building. This requires an agreement with the building manager to ensure that trust staff safety will be maintained and to comply with the policies and procedures put in place by the building manager. 5.8 Creation of the Lockdown Procedures 5.8.1 Each trust building or site should be capable of quickly achieving a partial or full lockdown in the event of any given emergency. These arrangements will vary in complexity depending on the size of the premises and the scale of the emergency. 5.8.2 For each building or site, an assessment will be made on the capacity and capability to lockdown which will feed into the creation of robust lockdown procedures for that separate premise and site. The level and robustness of the lockdown procedure is required. 5.8.3 The lockdown procedure is to be completed by the manager with the advice of the LSMS / Security Advisor if required. 9
6. TRAINING REQUIREMENTS 6.1 There are no specific training needs in relation to this policy, but the following staff will need to be familiar with its contents and should ideally have undertaken the Project Artemis training presentation: Facilities managers Managers of buildings, departments and sites Estates Managers Estates Officers Security Staff / Managers (where applicable) Any other individual or group with a responsibility for implementing the contents of this policy. As a trust policy, all staff should be aware of the key points that the policy covers. Staff can be made aware through a variety of means such as: Team briefings, Posters, Newsletters etc. 6.2 Legal Framework Article 5 of the European Court of Human Rights provides that no-one may be deprived of their liberty unless it is in accordance with a procedure prescribed by law. In the healthcare context in England and Wales, there are primarily three legal frameworks regulating a deprivation of liberty: Mental Health Act 1983 Deprivation of Liberty Safeguards Authorisation under the MCA 2005 Court order under s.16 MCA 2005 A lockdown, although a temporary measure, could still be construed as depriving a person of their liberty and as such, the above legal framework should be borne in mind. 7. MONITORING COMPLIANCE 7.1 As a minimum, the following will be monitored to ensure compliance: Element to be Monitored Procedure Table top lockdown exercises should be carried out in accordance with local procedures Training All staff locally who would be nominated to physically lockdown an area Lead Tool Frequency Reporting Arrangements Service / Annually Clinical Manager Service / Clinical Manager Lockdown Action Cards / Procedure Checklists. Staff Training Records & PDR Initially then 3 5 yearly Non-compliance will be reported through the H&S Committee and the Q&S Committee. Line Management responsibility 10
8. POLICY REVIEW 8.1 This policy will be reviewed a minimum of every four years, however this policy is to be reviewed 12-18 months after initial publication or in the event of any changes in legislation which may have an impact on procedures. 9. ASSOCIATED DOCUMENTS Risk Management System Risk Management Policy Health & Safety Policy Security Management Procedures Hazmat Policy 10. SUPPORTING REFERENCES: Mental Health Act 1983 (as revised 2007) Mental Health Act Code of Practice 1999 (as revised 2008) European Convention on Human Rights Department of Health. Patients Charter Nursing and Midwifery Council. Code of Professional Conduct June 2002 11
Site Profile For: Appendix A: CHARACTERISTIC INFORMATION REQUIRED STATUS LOCATION AREA SITE CHARACTERISTICS LANDSCAPE SUMMARY LOCAL ROAD ACCESS PUBLIC TRANSPORT ACCESS TRAFFIC MOVEMENT AROUND SITE NEIGHBOURING LAND ISSUES CAR PARK FACILITIES NUMBER OF BUILDINGS ON SITE TOTAL NUMBER OF OFFICIAL AND UNOFFICIAL ACCESS AND EGRESS POINTS ON THE TRUST SITE 12
Building Profile for:.. Appendix B: CHARACTERISTIC INFORMATION REQUIRED STATUS DESCRIPTION OF BUILDINGS PRESENT USE BASIC SHAPE HEIGHT OF BUILDING, NUMBER OF FLOORS AND THEIR USE CONDITION OF BUILDING CORRIDORS ACCESS AND EGRESS POINTS IN THE BUILDING CAR PARK FACILITIES FOR THE BUILDING EXTERNAL AND INTERNAL DOORS AIR CONDITIONING FACILITIES AND VENTS HOW IS THE BUILDING POWERED WHO OWNS THE BUILDING 13
Security Profile:.. Appendix B1 CHARACTERISTIC INFORMATION REQUIRED STATUS EXTERNAL DOORS TO MAIN BUILDING INTERNAL DOORS WINDOWS CCTV SECURITY LIGHTING ALARMS FOR SPECIFIC AREAS SECURITY FOR CAR PARKING SECURITY STAFF 14
Appendix C LOCKDOWN PROCEDURE A Checklist for the lockdown process. PRELIMINARIES Is there a building manager Were they involved in this assessment and procedure Have you completed the building profile Have you chosen the most suitable lockdown action card Have you printed it off with the Incident Response Plan Action cards Have you had discussions with other building occupiers Are all staff in the building aware of the need to work together Is the emergency action plan / policy in a readily accessible location ASSESSMENT Are all the doors lockable Are all the windows lockable Is your power supply protected as much as practicable Do you know how to turn off the air conditioning system (if fitted) Have you designated a single entrance for use in emergencies KNOWLEDGE Have all staff been notified of lockdown and what it is Do the Staff know where the emergency and lockdown action cards are Do the staff know who is to take charge if the manager is absent Do all staff know where the designated refuge office is (land line, mobile friendly and lockable) Do the staff know who to report to (Incident Co-ordination Centre (ICO) or On-Call Director/On-Call Senior Manager) CHECKING Testing your lockdown procedures (suggest the same time as your emergency plan test) Have you chosen a date and time Have you informed the Risk and Resilience Officer and the LSMS Have you arranged a debrief meeting PROCEDURE Is there a fast and effective process for notifying all the staff of a lockdown Do staff have access to the lockdown action cards Do staff know which windows and doors they are responsible for Do staff know which door is to be manned to control access and egress Do staff know which telephone is going to be used by the control room to contact them YES/NO YES/NO YES/NO YES/NO YES/NO 15
Appendix D LOCKDOWN ACTION CARD 1 SHFT occupied building COMMUNICATE LOCKDOWN STATUS (CONTROL) Lockdown instruction received, authorised by (identify Authoriser), and for what risk. Confirm lockdown with authoriser. Follow Incident Response Plan Start incident log/book. Communicate to all building occupants Lockdown vial all medium available. Ensure this is not a drill / practice is communicated. IMPLEMENT ASSIGNED RESPONSIBILITIES. (CONTROL) If required, call 999 and request assistance as needed. Out of Hours, notify the Trust Duty On-Call Director of building status. Out of Hours, notify the Trust Duty On-Call Director, Risk and Resilience Officer, LSMS of building status. Lock all exit (external windows and doors) points to the building. Assign duties of staffing main access point for emergency access via identity card only (excluding Chemical, biological, Radioactive or Nuclear (CBRN) incident). Hand over control to emergency services where it is a CBRN incident. Assign duties of controlling exit from the building where service users and visitors are present. Notify Director / Assistant Director of business division of status. BUIDING OCCUPANTS If riot or malicious individuals outside, close any curtains / blinds, stay away from windows and doors. Shut off lights. Be quiet. Do not use landline or mobile devices for anything other than lockdown. Await instruction, updates and / or all clear. Use supplies from lockdown kit. RECOVERY Resume normal operations ASAP. Ensure any after care where required and debriefings are carried out. 16
Appendix E LOCKDOWN ACTION CARD 2 SHFT controlled multi occupancy building COMMUNICATE LOCKDOWN STATUS (CONTROL) Lockdown instruction received, authorised by (identify authoriser), and for what risk. Confirm lockdown with authoriser. Follow Incident Response Plan - Start incident log/book. Communicate to all building teams / occupants Lockdown via all medium available. Ensure this is not a drill / practice is communicated. IMPLEMENT ASSIGNED RESPONSIBILITIES. (CONTROL) If required, call 999 and request assistance as needed. Establish senior team member (all teams occupying the building) lockdown team as previously practiced. Out of Hours, notify the Trust Duty On-Call Director of building status. Out of Hours, notify the Trust Duty On-Call Director, Risk and Resilience Officer, LSMS of building status. Lock all exit points to the building (external windows and doors). Assign duties of staffing main access point for emergency access via identity card only (excluding CBRN incident). Hand over control to emergency services where it is a CBRN incident. Assign duties of controlling exit from the building where service users and visitors are present. Notify Director / Assistant Director of business division of status. BUILDING OCCUPANTS If riot or malicious individuals outside, close any curtains/blinds, stay away from windows and doors. Shut off lights, be quiet. Do not use landline or mobile devices for anything other than lockdown. Await instructions, updates and / or all clear. Use supplies from lockdown kit. RECOVERY Resume normal operations ASAP. Ensure any aftercare where required and debriefings are carried out. 17
Appendix F LOCKDOWN ACTION CARD 3 SHFT Multi building sites Communicate Lockdown Status to building managers (Control) Lockdown instruction received, authorised by (identify authoriser), and for what risk. Confirm lockdown with authoriser. Follow Trust Incident Response Plan Start incident log / book. Communicate to all buildings teams / occupants Lockdown via all medium available. Ensure this is not a drill / practice is communicated. IMPLEMENT ASSIGNED RESPONSIBILITIES. (CONTROL) If required, call 999 and request assistance as required. Establish senior team member of lock down team as previously practiced (all teams occupying the buildings). Out of Hours, notify the Trust Duty On-Call Director of building status. Out of Hours, notify the Trust Duty On-Call Director, Risk and Resilience Officer, LSMS of building status. Lock all exit points to all buildings (external windows and doors). Assign duties of staffing main access point for emergency access via identity card only (excluding CBRN incident). Hand over control to emergency services where it is a CBRN incident. Assign duties of controlling exit from the building where serviced users and visitors are present. Notify directors / Assistant Directors of business divisions and external businesses of status. BUILDING OCCUPANTS If riot or malicious individuals outside, close any curtains / blinds, stay away from windows and doors. Shut off lights, be quiet. Do not use landline or mobile devices for anything other than lockdown. Await instructions, updates and / or all clear. Use supplies from lockdown kit. RECOVERY Resume normal operations ASAP. Ensure any aftercare where required and debriefings are carried out. 18
Appendix G LOCKDOWN ACTION CARD 4 Externally controlled multi occupancy building Carry out tasks detailed in Building Managers policy. If no lockdown in place, share this card. BUILDING MANAGER TO COMMUNICATE LOCKDOWN STATUS (CONTROL) Lockdown instructed / authorised by (identify authoriser) and for what risk. Confirm lockdown with authoriser Follow Incident Response Plan Start incident log / book Communicate to all building teams / occupants Lockdown via all medium available. Ensure this is not a drill / practice is communicated. BUILDING MANAGER TO IMPLEMENT ASSIGNED RESPONSIBILITIES (CONTROL) If required, call 999 and request assistance as needed. Establish a senior team member of each lockdown team as previously practiced (all teams occupying the building). Out of Hours, notify the Trust Duty On-Call Director of building status. Out of Hours, notify thetrust Duty On-Call Director, Risk and Resilience Officer Lock all exit points to the building (external windows and doors). Have duties assigned by building manager, staffing main access point for emergency access via identity card only (excluding CBRN incident). Hand over control to emergency services where it is a CBRN incident. Duties of controlling exit from the building where service users and visitors are present. Notify Director / Assistant Director of business division. BUILDING OCCUPANTS If riot or malicious individuals outside, close any curtains/blinds, stay away from windows and doors. Shut off lights, be quiet. Do not use landline or mobile devices for anything other than lockdown. Await instructions, updates and / or all clear. Use supplies from lockdown kit. RECOVERY Resume normal operations asap. Ensure any after care where required and debriefings are carried out. 19
Appendix H List of Critical Sites & Buildings within SHFT Aldershot Centre for Health Alton Community Hospital Alton Health Centre Andover War Memorial Hospital Andover Health Centre Ashurst Hospital (Annexe) Ashurst Hospital (Child & Family Centre) Becton Centre Chase Community Hospital Elmleigh Fareham Community Hospital Fenwick 2 Fleet Hospital Fordingbridge Hospital Gosport War Memorial Hospital Hythe Hospital & Medical Centre Milford on Sea Hospital Moorgreen Hospital (TRU) Lymington New Forest Hospital (Medical Services) Odiham Cottage Hospital Parklands Hospital (Parklands) Petersfield Hospital Romsey Hospital 20
Tatchbury Mount (1-3 Sterne) Tatchbury Mount (4-6 Sterne) Tatchbury Mount (7 Sterne) Tatchbury Mount (Bluebird) Tatchbury Mount (Dev & Train) Tatchbury Mount (Elms) Tatchbury Mount (Estates) Tatchbury Mount (Lodge) Tatchbury Mount (Maples) Tatchbury Mount (Rufus) Tatchbury Mount (Southfield) Tatchbury Mount (Sycamore) Woodhaven + Clockhouse 21
Appendix I Risk Assessment Matrix Location Date of Assessment Assessment No. L = Likelihood S = Severity 1 Unlikely 1 Superficial Injury 1-3 Low / No Action 2 Possible 2 Minor Injury 4-9 Med / Monitor 3 Probable 3 Over 7 Day Injury 10-15 High / Take Action 4 Highly Likely 4 Major Injury 16-25 Stop Action Imediately 5 Will Occur 5 Fatality Lockdown/HAZMAT Risk Assessment Location Address Postcode Main Contact Main activity of Site/Building List departments, including Multioccupancy/Tenancy INFORMATION THE RISK In terms of High, Medium or Low External Risks (Power station, prisons, nuclear power plants RISK Internal Risks (Hostages major spillages, fire, major crime RISK Brief description of site/buildings to include: Use of buildings Height THE ESTATE 22
Construction Basic shape Conditions Levels Access to the building Describe landscape Describe boundary and perimeter List neighbouring land issues and type (residential, industrial or recreational) Security lighting List areas of concern. Local road access. Public transport access Traffic movement around site. Clear signed including clear directional information to key areas. LIGHTING RISK Are all security lighting facilities working? Is external security lighting sufficient for: Car parking Paths Main entrances Side entrances Alcoves and vulnerable areas Are PIR /Proximity lighting systems working? Light fittings shall be vandal resistant and easily maintained? Air Conditioning facilities. Where controlled from? Maintenance responsibility How quickly can it be turned off? Does the unit have a natural ventilation system? Can this be zoned? How is the building powered? Location of switchboard/ Reception? How is this assessed? Do you require a key to access it? Location of water mains What override systems are in place? Number of fire zones. Describe fire zones. Location of fire panel? SERVICES Resources, Architect Plant FIRE Resources: architect services and facilities plans 23
CONTROL OF ACCESS Resources: architect services and facilities plans RISK Doors When are main doors locked? Describe types of lock. How are secondary doors (e.g. fire) locked? Describe types of locks. What is the state of repair of doors and door fittings? Do local procedures ensure staff secure doors at night? How often is combination settings changed? (ideally off site) Where are spare details of the settings Logged? (Ideally off site) Key/Fobs/Settings Controls RISK How are keys/fobs issued and recovered against a signature? Is a key/fob list regularly maintained? Does the site/unit/ward have a key/fob safe with a digital locking or tumbler device? How many sets of keys are? Where are spare sets located? (ideally remotely) Windows RISK Describe type of windows (e.g. pane, louver) Can all windows be locked? Are the current locks adequate? Do windows have opening restrictors? Are the current restrictors serviceable? Are windows and fittings in good repair? Is the glass of adequate security type? Supplier Provider List cameras and image range Location of CCTV monitoring area: CLOSED CIRCUIT TELEVISION (WHERE APPLICABLE) Resources: CCTV Plans Supplier Provider Monitored by: Which buildings are alarmed? How are they managed? How are they activated? Location of override panel. Show zones INTRUDER ALARMS ETC (WHERE APPLICABLE) Resources: Alarm/Intruder Detection Plans 24
GENERAL MATTERS Critical Assets RISK Medical Gases How stored? How secured? How often delivered? Describe Catering Deliveries Laundry Pharmacy /Medication Describe Laundry Deliveries Describe Medication Deliveries Location of PPE equipment How are CD and prescriptions secured? 25
Appendix I POST LOCKDOWN / HAZMAT EVALUATION TEMPLATE Question? Yes No Action(s) THE LOCAL LOCKDOWN POLICY Did the local Lockdown alert system work? Where all appropriate individuals informed? If so, how long did take for them to receive the information? Was the sequence for closing door/windows correct? If appropriate, were cordons set up in the correct order? During the Lockdown, was communication received quickly enough? Was the communication between Gold, Silver and Bronze command adequate? During the activation stage, were outcomes achieved? During the development stage, were outcomes achieved? During the maintenance stage, were outcomes achieved? During the stand-down stage, were outcomes achieved? Throughout the lockdown, were business continuity arrangements satisfactory? Question? Yes No Action(s) SECURITY FACTORS Was an alarm system activated at the onset of the lockdown? Did it work effectively? Did all of the locks function? Were all of them appropriate for the lockdown (for example, in terms of strength?) Where appropriate, did all of the external doors lock? Where appropriate did all of the internal doors lock? If appropriate, were any windows locked during the Question? Yes No Action(s) Lockdown? If so how effective was this? Were all identified access and egress points secured? If appropriate, could corridors be secured? 26
If it was a manual lockdown, was the site, building secured? If an access control system was used, was the site/building locked down? Were there any breaches in the lockdown? If so, where were they and were contained? Did security lighting support the Lockdown? If so how? If appropriate, was the car parking areas secured? Where cordons established? If so were they maintained? Were safety and control zones established? If so, were they maintained? If appropriate, during the Lockdown, was the air conditioning system successfully turned off? Question? Yes No Action(s) WORKFORCE Did all staff collect their action cards? Did the action cards reflect the staff roles during the Lockdown? If so do they need to be revised? Where appropriate, were the supporting Lockdown resources easily accessible? Did everyone collect their supporting Lockdown resources? Were all resource in the correct working order? Did staff take up their Lockdown location position in the agreed timeframe? Was there adequate number of staff to achieve the Lockdown? If not, how many extra staff will be required? Where they be sourced? Did all staff in Gold, Silver and Bronze command work to their correct remits? Were communications appropriate? For example, were communications sent to the right people at Question? Yes No Action(s) The right time? If appropriate, could all staff use their radios? Was joint working between internal and external stakeholders achievable? Were there any crowd management issues? If so what was the role of the staff in managing these? During the lockdown, did staff consider their own resilience? Has a staff de-briefing session been arranged to discuss their roles during the lockdown? 27
Appendix J Southern Health NHS Foundation Trust: Equality Impact Analysis Screening Tool Equality Impact Assessment (or Equality Analysis ) is a process of systematically analyzing a new or existing policy/practice or service to identify what impact or likely impact it will have on protected groups. It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. The form is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law. For guidance and support in completing this form please contact a member of the Equality and Diversity team Name of policy/service/project/plan: LOCKDOWN POLICY Policy Number: SH NCP 64 Department: Lead officer for assessment: Nigel Dowland: Local Security Management Specialist Date Assessment Carried Out: December 2014 Ricky Somal: Equality and Diversity Lead 1. Identify the aims of the policy and how it is implemented. Key questions Briefly describe purpose of the policy including How the policy is delivered and by whom Intended outcomes Answers / Notes Lockdown is the process of controlling the movement, access and egress of people around NHS property in response to an identified risk, threat or hazard that might impact on the safety and security of people and assets as well as the capacity of the that facility to continue to operate 28
2. Consideration of available data, research and information Monitoring data and other information involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. It can help you to identify practical steps to tackle any negative effects or discrimination, to advance equality and to foster good relations. Please consider the availability of the following as potential sources: Demographic data and other statistics, including census findings Recent research findings (local and national) Results from consultation or engagement you have undertaken Service user monitoring data Information from relevant groups or agencies, for example trade unions and voluntary/community organisations Analysis of records of enquiries about your service, or complaints or compliments about them Recommendations of external inspections or audit reports Key questions 2.1 What is the equalities profile of the team delivering the service/policy? Data, research and information that you can refer to The Equality and Diversity team will report on Workforce data on an annual basis. 2.2 What equalities training have staff received? All Trust staff have a requirement to undertake Equality and Diversity training as part of Organisational Induction (Respect and Values) and E-Assessment 2.3 What is the equalities profile of service users? The Trust Equality and Diversity team report on Trust patient equality data profiling on an annual basis 2.4 What other data do you have in terms of service users or staff? (e.g. results of customer satisfaction surveys, consultation findings). Are there any gaps? Consideration of HUMAN RIGHTS ACT The following must be considered: Staff when deciding to lock doors must be able to justify the decision as being for the protection of health and The Trust is preparing to implement the Equality Delivery System which will allow a robust examination of Trust performance on Equality, Diversity and Human Rights. This will be based on 4 key objectives that include: 1. Better health 29
safety of a service user or the public. The person in charge should also consider whether the health and safety of the service user or the public can reasonably be protected by any other means which will have a less intrusive effect upon the service user concerned and the other service users on the ward. The fact that these issues have been considered should be recorded by the person in charge when setting out their reasons for deciding to lock doors. outcomes for all 2. Improved patient access and experience 3. Empowered, engaged and included staff 4. Inclusive leadership If doors were locked because of inadequate staff resources without there being any consideration as to whether it is reasonable to provide further staff, this may leave the Trust open to challenge under Articles 5 or 8 of the Convention. The locking of a door must not be used as an alternative to considering whether a service user may need to become subject to the Mental Health Act 1983 and detained. 2.5 What internal engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? Service users/carers/staff 2.6 What external engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? General Public/Commissioners/Local Authority/Voluntary Organisations In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any potential negative impact on equality of opportunity for the target: In the case of negative impact, please indicate any measures planned to mitigate against this 30
Positive impact (including examples of what the policy/service has done to promote equality) Negative Impact Action Plan to address negative impact Actions to overcome problem/barrier Resources required Responsibility Target date Age Disability Gender Reassignment Marriage and Civil Partnership Pregnancy and Maternity Southern Health responds positively to requests for reasonable adjustments and also provides interpreting and translation services through Access to Communications. This can be accessed via the Equality, Diversity and Human Rights Policy No adverse impacts identified at this stage of screening Within Mental Health Units typically there is evidence that individuals who have a sensory or physical disability are more likely to have a poor experience of being admitted to hospital than non-disabled individuals. No adverse impacts identified at this stage of screening No adverse impacts identified at this stage of screening No adverse impacts identified at this stage of screening Applied to all protected groups: All service users in inpatient wards will have a care plan and Risk assessment which will be specific to their needs All service users in inpatient wards will have a care plan and Risk assessment which will be specific to their needs 31
Race Religion or Belief Sex Sexual Orientation Southern Health responds positively to requests for reasonable adjustments and also provides interpreting and translation services through Access to Communications. This can be accessed via the Equality, Diversity and Human Rights Policy A service user whose first language is not English may not understand the implementation of this policy. No adverse impacts identified at this stage of screening No adverse impacts identified at this stage of screening No adverse impacts identified at this stage of screening Interpreting and translation services provided by Access to Communications. Equality, Diversity and Human Rights Policy 32
Sign Off and Publishing Once you have completed this form, it needs to be approved by your Divisional Director or their nominated officer. Name: Designation: Signature: Date: 33