Document level: Trustwide (TW) Code: GR33 Issue number: 3 Lone worker policy Lead executive Director of Nursing Therapies Patient Partnership Author and contact number Safety and Security Lead 01244 397618 Type of document Target audience Document purpose Policy All CWP staff The purpose of this policy is to ensure that where services are provided by lone employees within the Trust's premises or local community, the risks associated are assessed and that effective management action is taken to ensure that measures to manage the risks are implemented and maintained. Document consultation Health safety and well being sub committee Approving meeting Health Safety and Well Being Sub Committee 5-Nov-12 Ratification Document Quality Group (DQG) 13-Nov-12 Original issue date May-09 Implementation date Nov-12 Review date Nov-17 CWP documents to be read in conjunction with HR6 CP6 GR1 GR8 GR35 EP1 Trust-wide learning and development requirements including the training needs analysis (TNA) Management of violence and aggression policy (incorporating verbal threat to staff and offensive weapons) Incident reporting and management policy Security policy Safe vehicular transport of service users and others Business continuity policy and procedures Training requirements Financial resource implications There are specific training requirements for this document. Training is in accordance with the CWP Training Needs Analysis No 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 Page 1 of 12
If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? N/A 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? What is the level of impact? No Low Document change history Changes made with rationale and impact on practice 1. Review of policy and format with new GP1 template 2. Page 4-3 Procedure - Inpatient 'line of sight' and Staff Attack Alarms 3. Page 5-3.1 Buddy System - updated with CCWC Lone Worker Device information 4. Page 6-3.3 Equipment - updated with CCWC Lone Worker Device information 5. Page 7 - Appendix 1 - Lone Worker Device protocol - new guidance 6. Page 8 - Appendix 2 - Identified Lone Worker (ILW) Protocol 7. Page 9 - Appendix 3 - Loss of Contact with ILW, Page 10 - Appendix 4 ILW Device protocol, 8. Page 13 - Appendix 5 - ILW Device Operational Procedure 9. Page 16 - Appendix 6 - ILW Devide continued 10. Page 17 - Appendix 7 - Emergency Usage Procedure for LWD 11. Page 18 - Appendix 8 Activated LWD protocol 12. Reference to Emergency Planning front cover and appendix 2 13. Appendix 3 last box removed on chart External references References 1. Health and Safety at Work Act 1974 and Good Employment Practice 2. NHS SMS Identified Lone Worker guidance (2009) 3. Data Protection Act 1998 Page 2 of 12
Monitoring compliance with the processes outlined within this document Please state how this document will be monitored. If the document is linked to the NHSLA accreditation process, please complete the monitoring section below. NHSLA Standard 4.2 Violence and aggression Minimum requirement to be monitored NB the standards in bold below are assessed at level 2/3 NHSLA accreditation Process for monitoring e.g. audit Responsible individual / group Frequency of monitoring Responsible individual / group for review of results Responsible individual / group / for development of action plan Responsible individual / group for monitoring of action plan and Implementation Arrangements making sure lone workers are safe How the organisation trains staff, in line with the training needs analysis How the organisation monitors compliance with all of the above Audit report Learning & Development report Safety and Security Lead L&D Manager Annual HSWSC HSWSC HSWSC At least 4 times a year WODSC WODSC WODSC As above As above As above As above As above As above HSWSC Health, Safety & Wellbeing Sub committee WODSC Workforce & Organisational Development Sub Committee Page 3 of 12
Content 1. Introduction... 5 2. Definitions... 5 3. Procedure... 5 3.1 Arrangements for making sure lone workers are safe (refer to appendix 1 for further information)... 5 3.2 The Buddy system... 6 3.3 Risk assessments (please refer to appendix 2 for further information)... 6 3.4 Lone working equipment... 7 3.5 Loss of contact with an ILW... 7 4. How the organisation trains staff, in line with the training needs analysis... 7 5. Duties and responsibilities... 7 5.1 Chief Executive... 7 5.2 Director of Operations... 7 5.3 Director of Nursing, Therapies and Patient Partnership... 8 5.4 Safety and security lead... 8 5.5 Health, Safety and Wellbeing Sub Committee (HSWSC)... 8 5.6 Workforce and Organisational Development Sub Committee (WODSC)... 8 5.7 Senior managers / heads of service responsibilities... 8 5.8 Line managers... 9 5.9 Identified Lone Workers (ILW)... 9 Appendix 1 - In-patient staff Lone Worker Devices (LWD) protocol... 10 Appendix 2 - Identified Lone Worker (ILW) procedure... 11 Appendix 3 - Loss of contact with identified lone worker... 12 Page 4 of 12
1. Introduction The NHS Security Management Service (SMS) has policy and operational responsibility for the management of security in the NHS. The aim of this policy, as set out in the national strategy, is to deliver an environment for those who work in or use the NHS that is properly secure so that the highest possible standards of clinical care can be made available to patients / service users. Where services are provided by lone workers within the Trust's premises or local community, the risks associated with lone working are assessed and that effective management action is taken to Trust recognises and accepts its responsibilities, in accordance with the Health and Safety at Work Act 1974 and Good Employment Practice. The term Lone Worker is used to describe a wide variety of staff who work, either regularly or only occasionally on their own and without access to immediate support from managers or other colleagues. This could be outside of a hospital or similar environment or internally, where staff care for patients or service users on their own. Other descriptions commonly used include community or outreach workers. Lone working may also be a constituent part of a person s usual job or it could occur on an infrequent basis, as and when circumstances dictate. Lone working is not unique to any particular groups of staff, working environment or time of day. There is not one single definition that encompasses all those who may face lone working situations and therefore may face increased risks to their security and safety. Health bodies, as employers, have a duty to implement procedures and systems for their employees to ensure, as far as is practicable, that safe working conditions exist. Procedures should underline safety issues and contribute to a safer working environment for lone workers, addressing all identified risks and providing staff with clear lines of communication place for the dissemination and use of these procedures, which should be subject to regular monitoring and review. Within the context of the Trust's overall policy, each team / department is required to supplement this policy by producing their own protocols and procedures based on risk assessments to assist employees in the local situation. 2. Definitions Lone working may be defined as - any situation or location in which someone works without a colleague nearby; or when someone is working out of sight or earshot of another colleague, Health and Safety at Work Act 1974 and Good Employment Practice. An Identified Lone Worker (ILW) is defined as - a wide variety of staff who work, either regularly or only occasionally on their own and without access to immediate support from managers or other colleagues, Health and Safety at Work Act 1974. A Buddy is defined as - a person who is their nominated contact for the period in which they will be working alone, NHS SMS Identified Lone Worker guidance (2009). 3. Procedure Health bodies, as employers, have a duty to implement procedures and systems for their employees to ensure, as far as is practicable, that safe working conditions exist. Procedures should underline safety issues and contribute to a safer working environment for lone workers, addressing all identified risks and providing staff with clear lines of communication place for the dissemination and use of these procedures, which should be subject to regular monitoring and review. 3.1 Arrangements for making sure lone workers are safe (refer to appendix 1 for further information) Within the context of the Trust's over arching policy, each service is required to supplement this policy by producing their own safe working procedures based on risk assessments to assist employees in the local situation. This would routinely apply to all staff working as part of an inpatient service, community team or any staff on-call outside of normal working shift pattern. Page 5 of 12
All inpatient services staff who are asked to work in situations that meet the lone working definition, such as carrying out escorted duties or observation duties out of line of sight must establish a point of contact and this will be the NIC and / or line manager for that shift duration. Staff Attack Alarms must be issued to those staff carrying out those duties as a priority, unless working outside of the inpatient areas due to the alarms not being able to be monitored. Where the Attack Alarms are not functional i.e. external to inpatient areas, staff must use the Buddy system (detailed within 3.2 below) as a method of maintaining communication with their base. 3.2 The Buddy system It is essential that Identified Lone Workers (ILW) keep in contact with colleagues and ensure that they make another colleague aware of their movements. This can be done by implementing various management procedures, such as the Buddy System. Overall the ward/team manager is responsible for ensuring that there are procedures and systems in place for the safety of their staff within their team. ILW in the community settings must ensure: That all work diaries are electronically updated daily; That all electronic work diaries be made available to the team manager or nominated deputy to access; That all personal contact details are updated and changes made known to their line manager. To support this process a member of staff can be nominated to ensure that the contact details and whereabouts of all ILW are known and available. This staff member is known as a Buddy, in the absence of a Buddy the contact details of each ILW must be accessible to the ward/team manager. The nominated buddy will: Be fully aware of the planned movements of the ILW; Have all necessary contact details i.e. mobile phone number; Access to personal contact details, such as next of kin (not appropriate for infrequent lone workers); Have details of the ILW known breaks or rest periods; Attempt to contact the ILW, if they do not contact the buddy as agreed; Follow the agreed local escalation procedures for alerting their senior manager or the police, if the ILW cannot be contacted or if they fail to contact their buddy within agreed and reasonable timescales. Essential to the effective operation of the Buddy System are the following factors: The buddy must be made aware that they have been nominated and what the procedures and requirement for this role are; Contingency arrangements should be in place for someone else to take over the role of the buddy in case the nominated person is called away to a meeting; There must be procedures in place to allow someone else to take over the role of the buddy, if the lone working situation extends past the end of the nominated person s normal working day or shift. 3.3 Risk assessments (please refer to appendix 2 for further information) Accurate and comprehensive assessments of all risks associated with service users and all environments should be undertaken in accordance with CWP Clinical Risk Assessment policy to ensure the safety of all. Examples of the Risk Assessment tools to be used are: Clinical Assessment of Risk to Self or Others (CARSO); HCR20; SVR20. Page 6 of 12
All assessments of risk should be viewed as a dynamic process that reflects changing patterns and needs. All clinical risk assessments and management plans should be reviewed regularly with the service user and care team members and include known trigger factors such as medication, mental state, cultural / belief issues and challenging behaviour as well as known previous successful interventions. Any change in the level of risk should be recorded, communicated by the nominated key worker and risk management plans changed accordingly. All completed risk assessments will be retained in the patients care records and monitored appropriately by the responsible clinical team. This log must be retained in accordance with the Data Protection Act 1998 and only strictly factual information should be recorded. The contents of the risk assessments must be available to Identified Lone Workers (ILW) to review ahead of any visit they make or with any duties they are asked to under take. Such information, must where legally permissible, be communicated with other agencies who may work with the same patients / service users, as part of an overall local risk management process. This is particularly important if there are known risks with a particular location or patients / service users. Identified Lone workers must remain alert to risks presented from those who are under the influence of drink, drugs, are confused or where animals may be present. Being alert to these warning signs will allow the ILW to consider all the facts at their disposal, allowing them to make a personal risk assessment and therefore, a judgment as to their best possible course of action for example, to continue with their work or to withdraw. At no point must the ILW place themselves, their colleagues or their patients / service users at risk or in actual danger. In the event that an ILW has been involved in an incident which involves risk to self or others all risk management plans will need to be updated and new ones formulated where required, all incidents must also be reported onto CWP Datix system. 3.4 Lone working equipment If an ILW has been given personal protective equipment, i.e. Lone Worker Device, mobile phone, pager or personal attack alarm, staff must ensure that they carry it with them ay all times and they know how to operate it. All faults noted with lone worker equipment must be reported and replaced before commencing or continuing their duty. In accordance with policy all staff must carry an up to date CWP identification badge, which must be visible during any visit (refer to all appendices for further guidance). 3.5 Loss of contact with an ILW Any incidents where by staff member is found to be non-contactable whilst on duty or when carrying out planned community visits must be taken seriously and action taken to establish contact (please refer to appendix 3 for further information). 4. How the organisation trains staff, in line with the training needs analysis All staff must complete the training as outlined within the Trust s Training needs analysis detailed within mandatory employee learning policy. 5. Duties and responsibilities 5.1 Chief Executive As Accountable Officer, the Chief Executive has overall responsibility to ensure that there are systems and processes in place to ensure that the searching of patients, public and facilitates is carried out within the legislative framework and that responsibility for this is delegated to an Executive Director. 5.2 Director of Operations Director of Operations has overall responsibility for the protection of lone workers by gaining assurance that policies, procedures and systems to protect lone workers are implemented and will ensure that there are: Page 7 of 12
Adequate security provision is made in their NHS body as specified in the Secretary of State Directions that ensures the safety of all lone working staff; Measures to protect lone workers comply with all relevant health and safety legislation, Secretary of State Directions and takes into account NHS SMS guidance. 5.3 Director of Nursing, Therapies and Patient Partnership The Director of Nursing, Therapies and Patient Partnership has responsibility for; The nomination and appointment of an accredited security management specialist and that through continued liaison ensures that security management work (including the protection of lone workers) is being undertaken to the highest standard; Overseeing the effectiveness of risk reporting, assessment and management processes for the protection of lone workers. Where there are foreseeable risks should gain assurances from the accredited security management specialist that all steps have been taken to avoid or control the risks. 5.4 Safety and security lead The safety and security lead is responsible for working with the Director of Nursing, Therapies and Patient Partnership, Human Resource Manager and other managers to investigate any incident of violence or security breach, to identify ways to reduce the risk further; The Safety and Security Lead is responsible for the formulation and review of this policy; The Safety and Security Lead is responsible for the development and for overseeing the facilitation of the lone worker presentation on CWP mandatory training programme in accordance with NHS SMS standards; The Safety and Security Lead has an active part in identifying hazards, assessment and management of the risks and to advise senior managers on the proper security provisions needed to mitigate the risks and protect lone workers; The Safety and Security Lead will advise the organisation on systems, processes and procedures to improve personal safety of lone workers and make sure that proper preventative measures are in place; The Safety and Security Lead will advise the organisation on appropriate and proportionate physical security, technology and support systems that improves personal safety of lone workers. Ensure that this is appropriate, proportionate and meets the needs of the organisation and lone working. 5.5 Health, Safety and Wellbeing Sub Committee (HSWSC) HSWSC is responsible for approval, ongoing review (including review of duties) and receiving reports on the monitoring of this policy, through receipt of reports, work plans and action plans as detailed in this policy. 5.6 Workforce and Organisational Development Sub Committee (WODSC) WODSC is responsible for approval, ongoing review (including review of duties) and receiving reports on the monitoring of this policy, through receipt of reports, work plans and action plans as detailed in this policy. 5.7 Senior managers / heads of service responsibilities Senior managers / heads of service have responsibility for ensuring the full implementation of this policy within their services; Senior managers / heads of service have responsibility for ensuring that risk assessments are carried out within their services and local arrangements developed to reduce the risks; The senior managers / heads of service responsibilities must respond to recommendations for remedial action to minimize risk following an assessment, incidents, audits or inspections by allocating funds or seeking resources / funds for the procurement of equipment or changes to working practice where it will reduce the risk of injury or ill health. Page 8 of 12
5.8 Line managers In accordance with CWP policy line managers have local operational responsible for reviewing and identifying situations where employees may be exposed to foreseeable risks etc. Verbal abuse, physical assault or a work related safety hazard. They are responsible for the undertaking and implementing of risk assessments and reviewing their effectiveness at intervals not exceeding one year or when a significant change in circumstances occurs and following any incident. Line managers must ensure that monitoring complies with the risk assessment recommendations and control measures set out by CWP. They are responsible for establishing clear procedures to set limits as to what can and cannot be done whilst working alone and where appropriate, when to stop work and seek advice. Line managers must communicate these measures clearly to Identified Lone Workers (ILWs) and to ensure employees receive appropriate essential training. Ensuring all untoward incidents are reported via agreed systems (see incident reporting and management policy). Line managers must ensure that other agencies are informed of risk assessments, any subsequent reviews and changes to the work plan, especially when planning changes in service provision, which takes account of possible risks to safety and make arrangements for their avoidance or control. Line managers must ensure that all risks from lone working are identified and that proper control measures have been introduced to minimise or mitigate the risks before the member of staff enters a lone working situation. 5.9 Identified Lone Workers (ILW) All staff must ensure that they carryout their duties in a safe manner and in full compliance with this policy. All staff must ensure that an up to date and relevant risk assessment is completed and reviewed for each patient in accordance with CWP policy. All incidents must be reported in accordance with CWP policy. ILW community staff must ensure that all work diaries are electronically recorded and accessible to their line manager or nominated deputy. ILW must ensure they do not enter into lone working situations where they feel that their safety or the safety of their colleagues could be compromised. A common sense approach must be adopted and encouraged by all Trust staff to carry out an assessment of the risks that they face at any given time. Also a attack alarm should be carried when appropriate, where attach alarms are not functional staff must use the buddy system. ILW must ensure awareness of all potential risks associated with lone working and are required to comply with the risk assessment recommendation, any local procedures laid down and to report to their manager any problems encountered whilst working alone. Employees will comply with instruction and training which is provided to minimise the risk to health. They must report to their line managers or occupational health, any personal conditions which may affect their capability to undertake certain activities, reporting and documenting any accidents, incidents, injuries or ill health conditions which may arise out of work activities. All staff must complete and maintain compliance with the Trust s programme of mandatory employee learning. Page 9 of 12
Appendix 1 - In-patient staff Lone Worker Devices (LWD) protocol Page 10 of 12
Appendix 2 - Identified Lone Worker (ILW) procedure Page 11 of 12
Appendix 3 - Loss of contact with identified lone worker Page 12 of 12