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Safety procedures for non-clinical staff and others working in clinical areas procedure

Contents

  1. Aim
  2. Introduction and scope
  3. Link to overarching policy
  4. Procedure
  5. Appendices

1 Aim

The aim of this procedure is to ensure that risks to non-clinical staff and others who are working in “high risk” clinical areas are minimised and that risks to patients and clinical staff are also minimised.

2 Introduction and scope

There is a need to have agreed procedures where work is being carried out in clinical areas where there is an increased risk posed by the patient group. The procedures are applicable to non-clinical trust staff, contractors, visitors and others who carry out work or may be present in these areas where patients will also be present. It is envisaged that trust staff will be provided with training on the risks and the precautions to be taken and will therefore not be required to complete the checklist in appendix A which is envisaged will be used for all contractors. The risks of working in “high risk” areas include but are not limited to:

  • patients obtaining tools, other sharp objects, chemicals and who may self-harm or use them to harm others
  • patients being disturbed by disruption and noise, potentially leading to agitation, frustration and disruptive behaviour.
  • physical attacks or verbal abuse on staff carrying out the work
  • privacy and dignity issues, for example, having to exclude patients from their room and potentially moving their belongings
  • accusations by patients of excessive disturbance and accusations relating to theft, or other unacceptable behaviours, particularly when work is carried out in bedrooms

At risk areas are nominally divided below:

High Risk areas

All areas of the sites which are accessible to patients:

Medium risk areas

All outpatient waiting areas, including:

Trust nursing and admin staff who are responsible for clinical areas need to be aware of the procedures and where appropriate they need to implement measures to reduce any identified risks.

This procedure is overarched by the lone working policy and also links to the clinical risk assessment and management policy and the management and control of contractors policy.

4 Procedure

It is important that these risks are not over-emphasised; creating unnecessary concern amongst staff that is disproportionate to the reality of the risks faced. It is therefore important that efforts to minimise the risks are based on fact.

4.1 Assessment of risk

A risk assessment may need to be carried out by the person in charge or a senior nurse. For planned work of a long duration (greater than 2 hours) a risk assessment must be completed by the person in charge of the area and the team carrying out the work. Where assistance is required from clinical staff to act as a safety person and where this cannot be provided, then the work may need be re-scheduled with a second person in attendance.

The risk assessment should be communicated to staff in the area and those who are carrying out the work. The risk assessment will be dynamic and based on local circumstances; the factors to take into consideration include, but are not limited to:

  • the patient group and risks that these may present
  • the potential risks that any individuals in the group may present, including the mood of individuals
  • the location of the work
  • the nature of the work
  • the duration of the work

4.2 Precautions to be undertaken

Trust staff who regularly carry out work in high and medium risk areas must certify that they have read and understood this procedure and should receive conflict resolution training which will allow them to recognise warning signs and what action can be taken should a situation develop. The precautions listed below have been included in a checklist (appendix A) which must be used by contractors for each visit or for each job. The precautions include:

  • any work to be carried out in a patient area should be reported to the person in charge of the area or a senior nurse
  • where it is deemed that there are risks which need to be mitigated then any non-clinical staff or visitors must be issued with a staff attack alarm or other suitable measures taken to reduce the risks

The person in charge or senior nurse should be requested to identify to the person carrying out the work the precautions that need to be taken which may include:

  • the person carrying out the work may be able to work on their own, by locking off the areas to be worked in
  • for work of a short duration, the person carrying out the work may need a member of nursing staff to act as safety person while the work is carried out, for example when working from steps and replacing a light in a common area such as a corridor
  • for work in a patient bedroom, where patient’s belongings have to be disturbed, a member of staff from the unit will be required to accompany the person carrying out the work. In all circumstances, the person in charge of the area should ensure that patient consent has been gained and that all valuables are secure

Appendix A will be used in addition to the ‘notice to contractors, workplace responsibilities’ which is used for contractor induction or acknowledgement of responsibilities. Completed forms by contractors will be retained for a minimum 3-month period, maximum 24-month period.

5 Appendices

5.1 Appendix A Checklist working in high and medium risk areas

Document control

  • Version: 2.3.
  • Unique reference number: 461.
  • Ratified by: Estates and sustainability CLE.
  • Date ratified: 8 April 2025.
  • Name of originator or author: Head of estates and development.
  • Name of responsible committee or individual: Director of finance and estates.
  • Date issued: 23 April 2025.
  • Review date: 30 April 2028.
  • Target audience: Trust staff, contractors and others who may work in the identified clinical areas.

Page last reviewed: April 23, 2025
Next review due: April 23, 2026

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