Lockdown of a trust premise, site or building policy and procedures

1 Introduction

Lockdown is the process of controlling the movement, access and egress of people in response to an identified threat or risk which could impact on the safety and security of persons and or assets or the capacity of a facility to continue to operate.

A lockdown may be implemented by the trust as part of a security incident or by enacting the major incident plan. This may be in partnership with other NHS or external bodies, for example, by the Police based on received intelligence.

There are a number of circumstances in which managers may need to lockdown an area under their control. These include but are not limited to:

a missing patient
a possible incident of violence and aggression
where staff, patients and other persons may be affected by an incident (for example, contamination of a reception area)

The ability to lockdown sites, properties or buildings fits in with the statutory responsibilities of NHS trusts as category 1 responders as defined by the Civil Contingencies Act 2004 and by the NHSE(I) core standards for emergency preparedness, resilience and response (EPRR).

2 Purpose

The purpose of this policy and procedure is to provide guidance to managers and staff to enable them to effectively lockdown an area which is under their control.

The policy should be read in conjunction with the business continuity plans and the major incident and major incident recovery plan, however it may be used on a standalone policy if required.

Many premises, sites or buildings which are occupied by trust staff have multi occupancy arrangements and the trust’s plan must fit with any overarching lockdown plan of the majority occupier.

3 Scope

This policy and procedure applies to all premises, sites, buildings or other areas which are under the control of trust staff. It requires all managers of such areas to work with the Safety team to prepare a procedure whereby the areas under the managers control can be effectively locked down when required. This may require collaborative working with other agencies or organisations.

This policy is to be viewed as complimentary to the trust’s security policy.

4 Responsibilities, accountabilities and duties

4.1 Security management director (SMD)

The executive director of Finance is the nominated security management director (SMD) with responsibility for overseeing security management within the trust.

The SMD is responsible for providing, so far as is reasonably practicable, a safe and secure working environment and ensuring the safety and security of staff, patients, and others who may be on the premises, sites, buildings or other areas which are under the control of the trust. The SMD delegates these duties to others within the trust.

4.2 Local security management specialist (LSMS)

The Local security management specialist (LSMS) is part of the trust’s Health and Safety team and is responsible for:

the development of this policy
evaluating and disseminating relevant guidance
the implementation of the policy across the trust
assisting with the creation of lockdown procedures
holding a central data base of all lockdown procedures for the trust
overseeing a review of these lockdown procedures at no less than 2 yearly intervals

4.3 Business continuity and emergency preparedness, resilience and response (EPRR) manager

The business continuity and EPRR manager is responsible for:

maintaining a current major incident and major incident recovery plan and related plans, policies and procedures
liaising with the LSMS or Safety team to ensure that this policy interfaces with the major incident and major incident recovery plan and related plans, policies and procedures

4.4 All managers

All managers are responsible for:

working with the Safety team to create lockdown procedures
deciding which lockdown action card should be implemented for each area
managing lockdown procedures and ensuring that all staff are aware of their roles within a lockdown scenario
displaying the relevant action card in staff only areas
providing a copy of the completed lockdown procedure to the Safety team
the implementation of lockdown procedures where appropriate
reviewing lockdown procedures at no less than 2 yearly intervals, or more frequently if there is an environmental or staff change which may impact on the procedure

4.5 Health, safety and security forum

The purpose of the health, safety and security forum is to:

receive key operational lockdown risk areas and assurances from the LSMS or Safety team
receive a report on progress with premises risk assessment reports
monitor the completion of the trust lockdown procedures against the trust premises list and the effectiveness of the lockdown procedures as they are practised
escalate any issues to the safety and quality operational group and quality committee through its minutes

4.6 All staff

All staff are responsible for:

assisting managers to create a suitable and sufficient lockdown procedure for their work area
participating in any lockdown exercise
complying and assisting in any implementation of a lockdown procedure

5 Procedure and implementation

5.1 Key principles of lockdown

The key elements to consider when locking down an area are:

preventing the entry, exit and movement of people in the area in order to exclude or contain staff, patients and visitors, depending on the location of the risk
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
ensuring that there is good communication between other persons who may be at risk, including other teams within a building, the on call manager and staff in neighbouring buildings if on trust sites
ensuring that there is clear communication between bronze, silver and gold levels of command and control

A lockdown may be either: partial, progressive or full.

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.

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 and exit from either an entire site or specific area, building or premises. 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 may have to be considered in a variety of situations, many of which require an immediate implementation.

It is clear that if an incident is occurring externally to an area, the senior member of staff in the area should have the authority to make a decision to lock the area as an immediate response to protect patients, staff and others.

Any lockdown during normal office hours (Monday to Friday, 9am to 6pm) will require the senior member of staff in the affected area to inform their care group director (if part of a care group) or their director (if part of support or corporate services).

Equally, a lockdown can be called out of hours by the on call manager (bronze) in response to a larger or impending risk.

Any out of hours lockdown will require reporting to the on call manager (bronze). They may liaise with the on call silver or gold contact for advice. The on call manager (bronze) will convey any decisions to the affected areas on whether a lockdown should continue, and when it is to end.

If a lockdown is implemented during normal working hours there should be regular communication between building occupants where the lockdown is occurring, and the care group or corporate director and staff in other buildings affected. Out of hours there should be regular communication between the on call manager (bronze) and staff in affected buildings.

At an early stage during a lockdown the care group or corporate director should call an online MS Teams meeting with the senior person in the affected location so that information about the reason for the lockdown can be shared and feedback can be given from the building(s) in lockdown. Out of hours this should be carried out by the on call manager (bronze) and on call silver or gold.

Detailed action cards are provided in appendices C to G.

5.6 Controlling access in the event of a lockdown

In the event of a lockdown all staff should note that although healthcare sites are open to the public and members of the public have an implied licence to enter them, the owner of the premises has the right to refuse access.

Whilst NHS staff can provide directions to individuals within areas under their control (for example, stating which exit someone can use), it is unlawful to forcibly prevent exit (with the exception of service users legally detained).

Nonetheless, there may be circumstances when a lockdown is desirable. If this occurs, staff can appeal to individuals to remain in the area identified for lockdown, ensuring that they are aware of the risks if they chose to leave. If individuals have mobility issues a suitable safe exit route should be identified that, as far as possible, takes account of these.

5.7 Guidance on developing plans for lockdown

Creating a lockdown procedure is a four-step process:

complete the building profile, this will help assess the risks that are present, and the complexities of locking the building down
choose the appropriate lockdown action card (appendices C to G), the lockdown action card is an aide memoire for staff to use if a lockdown is required
communicate with all the 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
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

The appendices to this guidance will assist managers (working in conjunction with the Health and Safety team), to be able to develop a lockdown procedure for areas under their control

5.7.1 Identification of local stakeholders

Stakeholders in this context are all persons or 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.

5.7.2 Building profile (appendix A)

Create a building profile to review the functionality and capability of locking down an area or premise 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 a ventilation system which could spread a contaminant
where power supplies are housed

5.7.3 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 to set up a refuge in the event of a major assault against the premise. Although unlikely to be required, it is preferable to have identified this room prior to it being required.

5.7.4 Lockdown procedure checklist (appendix B)

The lockdown procedure checklist is an aide memoire to ensure that the manager 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.

5.7.5 Lockdown action cards (appendices C to G)

Using all available information gained from the assessments detailed above, the manager will choose the most appropriate action card from the four choices:

lockdown action card 1 (appendix C) suitable for a building where trust staff are the only occupier and are fully responsible for the building
lockdown action card 2 (appendix D) suitable for a building which has multiple different occupants and teams, but is predominantly controlled by trust staff. This requires agreement amongst all occupants
lockdown action card 3 (appendix E) 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 F) suitable for building or area 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
lockdown action card 5 (appendix G) action card for care group director or silver equivalent and on call manager upon receipt of information that a lockdown is required or in progress

5.8 Creation of the lockdown procedures

Each trust premise, sites, building or area under a manager’s control 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 area and the scale of the emergency.

Each building is unique so it is important that for each premise, site, building or area an assessment is made of the capacity and capability to lockdown. This should be done by completing the building profile document (appendix A). The document will identify, amongst physical characteristics of the building:

who the manager is, they will usually be the lead for calling a lockdown, co-ordinating the process in their building, communicating the arrangements to their staff and acting as the point of communication if they are required to lockdown the building that was originally called in other premises on the site (progressive lockdown)
a refuge area for staff to move away from the source of danger

The building profile will indicate the local features and arrangements, including individual responsibilities and what exits and entrances need to be controlled. This should be used in conjunction with the correct action card (appendices C to F) to determine what action to take if a lockdown is called. The lockdown planning document (appendix B) must also be completed by the manager, with the advice of the Safety team if required, in order to confirm that suitable arrangements have been put in place.

Consideration should be given to the staff group in the building and whether there are any individuals with mobility issues to ensure that their needs can be met in the event of a lockdown (for example, having seating available).

Copies of the lockdown documents (appendices A and B) and relevant action card should be made available in each of the trust premises and staff should be familiarised with these arrangements. In addition to this, copies of all the trust lockdown documents will be held by the LSMS or Safety team who will be responsible for monitoring that the procedures are updated at the agreed period.

6 Training implications

There are no specific training needs in relation to this policy, but the following staff will need to be familiar with its contents:

managers and all staff
Safety team
estates managers
Any other individual or group with a responsibility for implementing the contents of this policy.

As a trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through a variety of means such as:

CPD sessions
newsletters
team meetings
one to one meetings
trust wide email
supervision
local induction

7 Monitoring arrangements

7.1 That the lockdown procedure for all areas of the trust is completed

How: Premises report.
Who by: LSMS.
Reported to: Health, safety and security forum.
Frequency: Bi-monthly.

7.2 Effectiveness of the lockdown procedure for each area

How: 2 yearly practice of full lockdown process in each area.
Who by: Safety team.
Reported to: Health, safety and security forum.
Frequency: Bi-monthly.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

There are no effects on the provision of privacy and dignity or respect within this policy.

8.2 Mental Capacity Act 2005

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005)to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

9 Links to any associated documents

This policy should be read and implemented in association with the following trust policies:

10 References

NHS Protect, SA20b Lockdown Guidance, restricted document available from the Safety Team.
NHSE(I) Core Standards for Emergency Preparedness, Resilience and Response (EPRR).

11 Appendices

11.8 Appendix H NHS protect lockdown guidance

This is a secure controlled document obtainable from the Safety team if required.

Document control

Version: 5.1.
Unique reference number: 218.
Ratified by: Corporate policies approval group
Date ratified: 11 January 2024.
Name of originator or author: Safety team.
Name of responsible individual: Corporate policy approval group, executive director of nursing and allied health professions.
Date issued: 12 January 2024.
Review date: April 2025.
Target audience: All managers of premises, buildings or areas within buildings, and any other individual or group with a responsibility for implementing the contents of this policy.

Page last reviewed: April 30, 2024
Next review due: April 30, 2025

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