Security policy

1 Introduction

NHS organisations are required to ensure that as far as is reasonably practicable, the delivery of healthcare takes place in a safe and secure environment.

Healthcare settings are increasingly being seen by criminals as a soft target for both thefts and acts of vandalism. There is a need to balance the needs of legitimate stakeholders to gain access against the security of individuals and the protection of trust owned and other assets. The trust has developed this policy to help reduce security risks to a minimum.

It is important that all staff recognise and act on their responsibility in relation to security, “keeping the NHS safe and secure is the responsibility of all who work in or use its services” (NHS Protect, 2005).

1.1 Definitions

Physical security, the security of premises, buildings, assets and objects (violence and aggression from patients or service users is detailed in the prevention and management of violence and aggression policy.
Assets, irrespective of their value, assets can be defined as the materials and equipment used to deliver NHS healthcare. The term can also refer to the personal possessions of staff and service users whilst at work or receiving trust services.
Overt CCTV, CCTV (closed-circuit television) monitoring which is clearly visible and not intended or designed to monitor any specific activity or individuals. It is allowed without permission as long as certain rules concerning what is visible on the monitor are complied with.
Covert CCTV, this is where a camera is hidden, or purposely not clearly visible, and it is reasonable to assume anyone being observed is unaware that they are being observed. Covert observation is not allowed without permission of the police.
Directed observation, where a particular person or activity is being observed whether overtly or covertly, the observer must obtain permission under RIPA (Regulation of Investigatory Powers Act) from the surveillance commissioners office before it is undertaken.
Permission, permission is required for covert and directed observation. Any requests must go through the security management director (SMD) or LSMS for advice.

2 Purpose

The purpose of this policy is to set out the arrangements for managing the physical security of premises and assets and to reduce security related risks to staff and other persons who have legitimate business with the trust.

The policy outlines procedures for implementing security measures. Whilst these measures are in place to protect both persons and property, a balance must be achieved so that the measures are a deterrent to criminal activity, but do not place unnecessary burdens on staff and service users or create an inappropriate environment.

3 Scope

This policy relates to the security of persons, premises and assets. It includes the control of keys, fobs and access systems, CCTV, weapons in the community and liaison with the police in any work-related situation or environment. All staff are expected to actively contribute to and co- operate with these security arrangements. The policy also applies to any other individual or group who may be present on trust managed premises or who use trust owned assets.

Reference should also be made to the prevention and management of violence and aggression policy and the lone working policy.

4 Responsibilities, accountabilities and duties

4.1 Chief executive

The chief executive has overall executive responsibility for security management within the trust. This responsibility is delegated to directors and managers in the trust.

4.2 Security management director (SMD)

The director of finance is the current nominated security management director (SMD) and has responsibility for security management within the trust. The role of the SMD includes but is not limited to:

promoting and leading on security matters at board level to ensure legal compliance
overseeing counter fraud issues and investigations in accordance with the legal directions and the NHS counter fraud manual and NHS executive fraud and corruption manual
reporting any significant security issues at regular intervals to the trust’s audit committee

4.3 Directors and heads of service

All directors or assistant directors and heads of service are responsible for security in areas under their control. This includes ensuring that staff are appropriately trained, that a security culture is embedded in day to day operations and that security risk assessments are in place for all areas under their control.

4.4 Managers

Duties of managers in relation to security for areas under their control include but are not limited to:

ensuring that a security risk assessment is carried out, regularly reviewed and that any actions arising are addressed
working with the Safety team to create a lockdown risk profile
ensuring that systems are in place for the use of access control and intruder alarm systems and implementing suitable procedures for the control of keys, fobs etc
ensuring that all security incidents are reported and investigated with the assistance of the trust’s Safety team
reviewing security measures at least annually or sooner if security breaches occur or where service changes necessitate this
ensuring that staff attend security related mandatory training. This includes conflict resolution, security and personal safety and prevention and management of violence and aggression training
liaising with the Safety team before changing any security management system such as fitting new locks or door access systems

4.5 Local counter fraud specialist (LCFS)

Duties of the LCFS include but are not limited to:

raising awareness of fraud issues and acting as a central link for counter fraud issues across the trust
undertaking counter-fraud work and fraud investigations
providing advice to the SMD on all aspects of fraud, bribery and corruption
maintaining an overview of all police cases where fraud is involved
reporting to the trust’s audit committee

4.6 Local security management specialist (LSMS)

The LSMS is a member of the trust’s Safety team.

Duties of the LSMS include but are not limited to:

acting as a focus for security related matters
investigating security incidents, including violence and aggression
liaising with the police
referring any instances of suspected fraud, bribery and corruption to the counter fraud specialist
publicising any security incidents, where lessons can be learnt
providing an annual security report
carrying out workplace security inspections in conjunction with service managers and assisting the manager to complete any actions identified
conducting security surveys and security risk assessments where a workplace security inspection demonstrates a more detailed risk assessment is required
in conjunction with service managers, create a lockdown risk profile for each property or site within the trust
assisting in drawing up specifications for security improvement work
acting as an authorising officer for the release of CCTV and other images. This includes, creating a CCTV inventory, approving the release of material to authorised officers and obtaining images or video clips in connection with security incidents
approving the release of the material to authorised officers and keeping signed records of such releases in accordance with the trust’s information governance polices
obtaining images or video clips in connection with any security incident in compliance with the trust’s information governance polices

4.7 Head of estates and facilities

Duties of the head of estates and facilities include but are not limited to:

ensuring appropriate physical security of trust premises, including making sure premises are secure as soon as practicable in the event of damage presenting a security risk
ensuring the maintenance of security related systems such as alarm systems, access control and CCTV installations is carried out where the budget for these systems is held by estates
assisting managers and the Safety team in identifying deficiencies in security systems
ensuring that new builds and alteration work within the trust includes funding for appropriate security measures, which may include:
- a means of access control whether it is keys, combination locks, fobs, and swipe card or proximity detectors
- an intruder alarm system
- a CCTV system
- external lighting to vulnerable areas
- security measures to ground floor windows such as shutters, bars or grilles
- staff attack and nurse call systems

4.8 Estates managers or officers

Estates managers or officers involved in planning or organising new building works or refurbishment schemes must liaise with the service manager and Safety team to ensure that all security related issues are considered.

4.9 Health and safety lead

Duties of the health and safety lead include but are not limited to:

collecting and collating security incident data submitted through the incident reporting (IR1) system and carrying out analysis for inclusion in the annual health and safety report or any other ad-hoc reports
co-ordinating the trust’s Safety team in the management of security across the trust

4.10 All staff

All staff employed within the trust are responsible for:

complying with the security procedures in their workplace
making full use of personal protection or alarm devices and of any installed security measures within their own building
reporting suspicious activity or actual incidents on the trust’s incident reporting system
reporting what they believe to be a serious security incident to the local police, their manager and to the trust’s Safety team
if safe to do so, politely requesting any unknown person within their area of work to reveal their identity and nature of their business. Failure of any person to give such details should be treated as a security incident and reported immediately
wear their trust ID badge at all times whilst on duty. If the visible wearing of a trust ID badge is not suitable, the member of staff must have the ID badge on their person and must produce it if requested
reporting any suspicious activity that they believe could lead to, or actually is, fraudulent, to the counter fraud specialist
staff leaving the trust should return any such equipment. Appendix G of the policy provides further guidance

Where staff have been nominated as CCTV authorised users to monitor local CCTV their duties include:

referring requests for the release of images to the LSMS or the trust’s Information Governance team. Note that images or information related to these can only be released by the LSMS or the trust’s Information Governance team
viewing and archiving of images and sequences
printing and copying images or sequences and storing them securely
ensuring that the CCTV system remains functioning and reporting any problems

4.11 Health, safety and security forum

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

actively champion security, promoting incident reporting, learning from experience and best practice
discuss and review the incident reports, trends and themes and facilitate learning and improvement through appropriate action
monitor risk assessments of the physical security of premises and assets and take an organisational overview of these, making recommendations as appropriate
monitor the completion of the trust lockdown profiles against the trust premises list and the effectiveness of the lockdown procedures as they are practised
escalate significant security incidents to the relevant committee
receive reports on significant operational risks
review the annual health and safety report which contains the annual security report

5 Procedure or implementation

5.1 Risk assessment

A security risk assessment should be carried out by the building manager or LSMS before premises are occupied and reviewed every 2 years or more frequently if circumstances change. For example, if there is a change in building function or a security incident occurs. The Safety team will carry out inspections of the security arrangements every two years. Appendices A and B provide details of the assessment process and what is assessed.

Copies of the completed risk assessment will be sent to the relevant managers detailing any required action to be taken, including the implementation of any recommended control measures. It is the responsibility of the relevant manager to coordinate the completion of the actions by the deadline given in the action plan. Updates should be sent to the Safety team.

If an area has complex security needs, the Safety team will work with the manager to complete a more detailed risk assessment. If risks are not, or cannot be managed at a local level, they will be escalated by the manager through the risk register process.

In multi-occupancy buildings, the managers of the various services within the building must liaise and agree a process for the completion of the risk assessment and management of security in general.

The Safety team will maintain and monitor a database of security risk assessments.

5.2 Security of trust properties and assets

Where properties and assets are managed by or are in the control of the trust:

all buildings will be provided with a means of access control whether it is keys, combination locks, fobs, swipe card or proximity detectors. If the building has a public access area such as a foyer or corridor, then access control should ensure that non-public areas are secure
buildings will be provided with an intruder alarm system where appropriate
vulnerable external areas of properties should be provided with external lighting
consideration should be made of the level of security required for ground floor doors and windows based on the value of the contents and the cost of measures such as bars and grilles, if appropriate
all buildings are to be left locked and secure, with appropriate security systems activated, access doors and gates locked and keys returned to relevant key holding areas
all staff must be aware of the security arrangements for the building and their role in maintaining the security. This includes familiarisation with the lockdown process

Where properties and assets are not under the direct control of the trust:

trust staff should assist the property owners or managers and other occupants to maintain security of the property and its assets
if the building does not meet the requirements of this policy, the relevant manager will discuss the matter with the building owners or managers and come to an agreement on how to ensure the building security is adequate to protect trust staff and property. If an agreement is not possible, the matter should be reported to the Safety team

5.3 Security of personal property

Staff should remain vigilant and when possible secure their personal property against loss. Where lockers are provided, they should be used and kept locked at all times.

Service users should be persuaded, where possible, not to bring valuable items or large sums of money onto the premises.

Where property is handed over for safe keeping this should be recorded in accordance with the procedures specified in the relevant trust policies or local safe operating procedure.

5.4 Personal security of staff

The trust has taken a number of measures to protect the personal security of its staff which include:

the installation of security and panic attack alarms systems
the issuing of lone worker alarm devices, where identified by risk assessment
the installation of appropriate lighting, fencing and CCTV
the provision of suitable training for staff
a consistent approach in relation to acts of theft, vandalism or assault

5.5 Security of service user areas

Service user areas need to be welcoming and approachable to visitors and others, however the security and safety of service users must be the first priority. There should be a balance of security measures which restricts access to intruders whilst providing access to legitimate users. Where possible, and with regard to fire escape requirements, service user care areas should be securely locked at night and staff should challenge all strangers. The vigilance of staff is a major defence.

5.6 Lockdown

The aim of a lockdown is to exclude or contain people by preventing entry to, exit from, or movement around a building or site. In some cases lockdown of individual buildings within a larger site may be required. This is required as a response to a threat or emergency which may endanger the wellbeing of service users, staff or visitors. This threat could range from airborne dangers such as toxic smoke, to a bomb threat, to a dangerous individual on the premises.

For each property an assessment will be made on the capacity and capability to lockdown, which will feed into the creation of robust lockdown procedures for that property. The level and robustness of the lockdown will be dependant on a variety of factors and a specific lockdown risk profile is required.

Refer to the lockdown of a trust site or premise policy for further guidance.

5.7 Car parking and vehicle security

The main points related to vehicle security are set out below:

lease car drivers must lock their vehicle and activate the security device or alarm in accordance with the instructions for use of the vehicle
personal items and any trust property must be removed from view when the vehicle is left unattended, thus limiting the possible risk of theft and damage to the vehicle
staff should lock vehicles and where security devices are fitted to the vehicle then these should be activated
park in a well-lit area

5.8 Lost and found property

All lost property incidents are to be investigated at ward or department level in the first instance and must be reported on an incident report form. Should it be identified that other trust staff are responsible for the loss; affected staff are to seek advice from their manager regarding compensation for the loss. Any found property is to be handed in to the main reception for safe keeping.

5.9 Cash handling or petty cash

Procedures for the handling of cash must be in line with the trust’s standing financial instructions. Any discrepancies in cash should be reported immediately.

The minimum control measures for cash handling are:

two people must be present when cashing up and preparing cash for banking
cashing up and preparing money for banking should not take place in view of the public
cash must be stored in a locked safe that is secured until transferred to a bank
at least two people must escort the money to the bank or secure location
banking should be carried out regularly (ideally daily)
times and routes should be varied when transporting money regularly. Wherever possible, vehicles should be used
wards and departments are to hold only the minimum amount of cash that is necessary
managers are responsible for ensuring that they have enough staff who are authorised signatories to enable service user banking to take place

5.10 Security of keys

Further guidance on the security of keys, fobs and electronic access control systems is provided in appendix G. The main points are set out below:

when staff leave the trust or move to another department the manager must retrieve any keys, fobs and other security devices held by the staff member
the manager for any department or ward which has key boxes is responsible for ensuring that it is kept locked at all times
the control of keys etc. is the responsibility of the manager and replacements will have to be funded from department budgets. New keys etc. will only be supplied when locks are found to be defective or exchanged

5.11 Drug or medicine security

The trust’s safe and secure handling of medicines manual and local standard operating procedures must be followed at all times.

5.12 Information and records management

All trust staff must comply with the trust’s information governance

5.13 Security incident reporting

All security incidents must be reported to the manager and an incident report form completed. Appendix C provides information about what must be reported. For more serious incidents, the police and the trust’s Safety team should be informed. Contact details are provided in appendix D.

All incidents of crime should be reported to the police by the manager. The manager will liaise with the police to follow up the report.

Suspicions of fraud, bribery and corruption should be reported to the counter fraud specialist and dealt with in accordance with the counter fraud, bribery and corruption policy.

Refer to the incident management policy for detailed guidance on incident reporting.

6 Training Implications

6.1 System controllers on the use of the CCTV system

How often should this be undertaken: Once.
Length of training: System dependant.
Delivery method: Face to face.
Training delivered by whom: System manufacturer or installer.
Where are the records of attendance held: Locally in personnel files.

7 Monitoring arrangements

7.1 Compliance with NHS protect security standards

How: LSMS work plan and security report.
Who: LSMS or health and safety lead.
Reported to: Health and safety forum.
Frequency: Annual report.

7.2 How the trust risk assesses the physical security of premises and assets

How: LSMS work plan and security report.
Who: LSMS or health and safety lead.
Reported to: Health and safety forum.
Frequency: Annual report.

7.3 How action plans are developed as a result of risk assessments.

How: LSMS work plan and security report.
Who: LSMS or health and safety lead.
Reported to: Health and safety forum.
Frequency: Annual report.

7.4 How action plans are followed up

How: LSMS work plan and security report.
Who: LSMS or health and safety lead.
Reported to: Health and safety forum.
Frequency: Annual report.

7.5 Departmental compliance with security requirements

How: Security inspections
Who: LSMS or Health and Safety team.
Reported to: Department manager and care group director.
Frequency: Every 2 years.

7.6 Security incidents

How: Review of incident reports and investigations.
Who: PMVA Training team.
Reported to: Relevant manager.
Frequency: As required after each incident.

7.7 Multi-agency liaison meeting

How: Minutes of the meetings.
Who: Chair of the meeting.
Reported to: Mental health liaison committee.
Frequency: Quarterly.

7.8 Audit committee

How: Minutes of the meetings.
Who: Chair of the committee.
Reported to: Board of directors.
Frequency: Quarterly.

8 Equality impact assessment screening

The completed equality impact assessment for this policy has been published on this policy’s webpage on the trust’s website. Link to equality impact assessment: Security policy EIA.

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

10 References

11 Appendices

11.1 Appendix A Workplace security risk assessment process flow chart

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

Workplace security risk assessment process flow chart, detailed below.

Safety team or manager completes workplace security inspection or risk assessment form:
- any actions required are identified from the form and action plan, manager seeks further advice from the Safety team if required:
  - significant risks are entered on the care group risk register
  - risk register is monitored monthly by the care group and bi-annually by the SLT
- copy of form sent to relevant manager and director, Safety team enters inspection findings on the performance database:
  - completion of form recorded on premises database held by Safety team
  - exception reports presented to health and safety forum and care group quality meetings
Safety team liaises with manager to create further action plan or expand existing action plan.
Manager is responsible for implementing the action plan.
Safety team obtains update on action plan at or near completion date.
If not completed, exception report is prepared for health and safety forum or relevant care group quality meeting.
Exception reports presented to health and safety forum and care group quality meetings.

11.2 Appendix B Security inspection or risk assessment form

Appendix B Security inspection or risk assessment form

11.3 Appendix C Reporting security incidents

Under this policy directors or managers have an obligation to put into place reasonable security measures in areas under their control. It is the responsibility of all staff within the trust to report any security incident or anything suspicious behaviour.

All incidents are to be reported to the manager of the area or service concerned and an incident report completed on the Ulysses incident reporting system (IR1).

For serious or potentially serious incidents one of the Safety team must be contacted by telephone or email, details are provided in appendix D.

If the incident occurs within a building that is in the control of another, follow their reporting procedures as well as the trust’s.

If an incident involves a crime being committed, then the police are to be informed.

11.3.1 Guidance on the type of incident that needs reporting

Being the victim of a theft.
Being the victim of an assault.
Being verbally threatened by staff or visitor or service user.
Being a member of staff who has discovered a burglary or theft in their environment or place of work.
Walking into a situation on trust premises, for example, car park, the grounds, place of work and foiling an attempted theft or vandalism or assault.
Unknown persons refusing to give details of their name or business.
Any other incident which is out of the ordinary, raises suspicion, or other concern.

11.3.2 Guidance on completing incident report forms

The form is obtainable via the trust’s Intranet home page.
If unsure how to complete the form, there is guidance available to download from the home page.
It is the responsibility of the member of staff who is involved to complete the incident form, or if they are unable, their manager.
The form will automatically be e-mailed to the designated manager and Safety team.

11.3.3 The purpose of incident report forms

Completion of the incident report form allows the trust to compile statistical data on incidents to facilitate analysis for issues, such as time of day, location, date, specific individuals involved and the types of incidents, for example, money theft, car damage, intimidation, physical or verbal assault. By analysing and monitoring the statistics, more effective strategies for prevention can improve their approval.

11.4 Appendix D Contact details

11.4.1 Police

For all emergencies contact the police on 999 (2222 or 9-999 in some units).

To contact the police for non-emergency reporting use the number 101 or:

South Yorkshire police: 0114 220 2020
North Lincolnshire police: 0845 606 0222
North East Lincolnshire police: 0845 606 0222

11.4.2 Safety team

Email: rdash.safetyteam@nhs.net

11.4.2.1 Safety team members

Bob Marrison, Security Advisor:

Jill Cross:

Telephone: 01302 796728
Email: jill.cross4@nhs.net

Ann McLeod

Telephone: 01302 794028
Mobile: 07876 560258
Email: ann.mcleod1@nhs.net

11.5 Appendix E CCTV systems

The trust has closed circuit television (CCTV) systems for the purposes of the prevention and detection of crime, deterring vandalism and unauthorised access at both internal and external locations.

This appendix describes:

the responsibilities and duties of trust staff in relation to CCTV systems
the CCTV management systems in place within the trust
the arrangements for archiving and the reproduction of photographic images or video sequences
to which persons or organisations the images and sequences can be released to

This appendix will not apply to systems under the control of third parties and relates to overt CCTV only.

11.5.1 Over CCTV

In consideration of the relatively large sites within the trust and the number of separate buildings, car parks and large number of departments, it is not possible for all areas to be monitored continuously. The use of pan and tilt rotating cameras can provide suitable coverage in many areas.

Notices advising of the existence of CCTV and ownership and its purpose will be displayed at the entrances to sites in prominent locations, clearly visible and legible.

Where managers identify situations where the installation of overt CCTV would be desirable they will contact the trust’s Safety team who will conduct an assessment and, depending on findings, draw up a specification for cameras, monitor and recording systems as appropriate.

A CCTV camera and system will only be installed if it does not contravene the legislation and it will be a viable and cost effective solution. CCTV must comply with this policy and current best practice.

11.5.2 Covert or other CCTV

No CCTV camera is to be placed where the privacy and dignity of a service user may be compromised. This includes toilet and ablution areas, bedrooms, dormitories or similar.

To protect service users, staff and visitors, CCTV may be placed in communal areas, such as corridors and entrances.

In the case of areas where a highly dependent vulnerable individual is placed, such as a seclusion room, a CCTV monitor may be installed after discussion with the clinician in charge and the Safety team.

11.5.3 Residential implications

The installation of CCTV cameras will be selected to eliminate, as far as practicable the overlooking of residential property not owned by the trust.

There is no intent whatsoever to focus on adjacent residential or commercial property. Individual privacy will be safeguarded and private and family life and the home respected.

11.5.4 Monitors

All CCTV imagery is subject to the principles of the Data Protection Act, including the live images which are being recorded and played back. Any monitor attached to a CCTV system must be positioned in such a way that the image cannot be viewed by anyone not entitled to view it.

11.5.5 Protocol for use of overt CCTV with recording capability

The following points must be followed when it is proposed to archive, download to suitable medium or produce a photographic image of any incident.

The authorised user (CCTV) with responsibility for overseeing CCTV will view the sequence of material and archive the relevant sequence or sequences.
They will record the date, time, camera number and a brief description of the incident in a logbook.
If approved by the Safety team or Information Governance team they will download the sequence to a suitable medium and, or produce photographic images and pass those on to authorised individuals.
The logbook will be held by the system controller.
All recorded material is to be kept in a locked secure location (cupboard, desk drawer etc.) until collected by the person or organisation making the request.
The sequences, which are judged to be still relevant to further investigations, will be retained as appropriate.
The archived sequences will be deleted as and when approved by the Safety team or Information Governance team.

Disclosure includes the viewing of images as well as providing recorded media, photographic images and information gained from the images.

Disclosure of images from the CCTV system must be controlled and consistent with the purpose for which the system was established.

For example, if the system is established to help prevent and detect crime it will be appropriate to disclose images to authorised law enforcement agencies where a crime needs to be investigated. The authorised individuals to whom recorded media and photographic images are released will be assumed to be responsible for any further reproductions and hence any liabilities under any relevant legislation such as the Data Protection Act, the Regulation of Investigatory Powers Act and the Human Rights Act.

Authorised law enforcement agencies are:

a police force
the National Criminal Intelligence Service
the National Crime Squad
the Commissioners of Customs and Excise
the Commissioners of Inland Revenue
any of the intelligence services
any such public authority not falling within those above as may be specified for the purposes of this subsection by an order made by the Secretary of State.

Any other person or organisation wishing to view images must be referred to the Safety team or Information Governance team.

Requests from staff for members of the public for images must be made in writing to the trust. In all such cases a consideration will be made about the duties under the Data Protection Act and whether this duty would be breached by releasing the images. The trust will inform individuals of relevant legislation and their responsibilities.

All requests for data must be accompanied by a data protection act, section 28/29 request and release form (as detailed on page 29).

11.5.6 Recorded material

Recorded material:

shall only be used for the purpose defined in this policy
shall not be sold or used for commercial purposes or the provision of entertainment
is the property of the trust who own copyright of all recorded material
authorised individuals shall be permitted access to specific recordings where necessary for the investigation and detection of a particular offence or offences or for the prevention or detection of crime
will be maintained securely and only authorised trust staff will have access
is to be destroyed or deleted after 28 days unless required for the detection and, or prosecution of a crime, or other legal process
Appendix E CCTV systems request for disclosure of personal data

11.6 Appendix F Weapons in the community

11.6.1 Section 1, general guidance

The use of and access to weapons by individuals in society is recognised nationally as being problematic. There have been high profile incidents that have involved individuals who have had a diagnosed mental illness, either injuring people with a weapon or being injured because they did or were thought to have a weapon.

This guidance is aimed at providing direction to staff as to how the potential risk of individuals having access to weapons should be considered and managed in a measured way.

It is recognised that staff are not expected to be experts or even knowledgeable in the identification of weapons and their legality.

It is important that staff recognise that the availability of weapons needs to be considered and evaluated as part of a risk management process, particularly if and, or when the individual experiences an exacerbation of their illness.

This appendix has been drawn up to support staff actions when:

they become aware that a service user has access to a weapon in the community
the discovery of such items causes concern, which requires action

It is recognised that each case is different and the response will have to be individually considered, taking into account the context of the situation.

Reporting to the police may not lead to any direct action from them, but could and should provide the care team with advice and guidance as to how to manage the situation.

It is recognised that any object involved in threat or attack can be described as a weapon and commonly include knives, broken glass, needles and other sharp objects. Also seemingly innocent household items could easily be utilised to threaten or cause injury, for example, cutlery, baseball bat, chair leg etc.

This guidance relates specifically to the observation of more clearly defined and specifically manufactured weapons (even if made by the individual owner).

This is important as even non-threatening carriage of these items, could cause members of the public to be concerned and call the Police this creating a danger or distress for the service user.

An offensive weapon is legally defined as any article made or adapted for use to cause injury to a person, or intended by the person having it with him for such use.

A firearm is a lethal barrelled weapon of any description from which any shot, bullet or other missile can be discharged.

An imitation firearm means anything, which has the appearance of being a firearm.

Prohibited weapons include any air-rifle, air gun, air pistol which uses or is designed or adapted for use with a self-contained gas cartridge system.

Knives, it is an offence to be in possession in a public place of any article, which has a blade or is sharply pointed (including a folding pocket knife if the cutting edge of its blade exceeds 3 inches). This covers all designs of bladed object, whatever its original function.

In the home consideration should be given to blades in an unexpected or unusual place. For example, a kitchen knife placed on a fire surround or sideboard, or a craft knife on a surface when there are no other craft items around. This may indicate that a threat exists and staff should act accordingly.

11.6.2 When urgent action may be needed

This is more often where the member of staff observes a weapon and feels under threat, or others are at risk.

Also, any firearm which is not securely stored should be considered as an imminent risk unless other factors reduce the risk.

If an imminent risk is perceived, the following actions should be undertaken.

Upon finding, suspecting or being told that a service user has a weapon(s) the staff should:

remove themselves and where possible others to a safe place
phone 999 immediately and provide the police with as much information as possible (it is essential that as mulch accurate information regarding individual, risk, weapon, potential victims etc., is shared. This will be used to grade or prioritise the police response)
follow safety instructions provided by police
inform line manager or manager on call
complete a trust incident form
complete an entry in the patient’s notes
place an alert or warning on the clinical records system

11.6.3 Where non-urgent action is needed

This is where staff have recognised that the service user has access to weapons but where there is no perceived immediate threat to self or others.

Consider discussion with the service user, as there may be an explanation what will inform future actions and decisions.
Identify and record the situation in which the weapon was found, for example, in a locked cupboard, on a coffee table, used as an ornament.

Assess the current mental state of the service user who has access to the weapon, paying particular attention to any imminent risk factors associated with the weapon.

The decision as to how to manage this situation should be taken within the multi-disciplinary team. If it is not possible to convene a full meeting, the discussions with team members should take place to ensure:

actions agreed are representative of all staff involved
all staff are aware of their responsibilities, in relation to the agreed action
risk of a public safety concern is considered objectively
complete an entry in the patient’s notes

11.6.4 Risk issues to consider

The multi-disciplinary team should consider the issues below in order to identify whether there is a public safety issue. The risk issues identified are not prescriptive or exhaustive but will help facilitate a full consideration of the risks.

Is the weapon safely stored or secured?
Is the item accessible by children or other vulnerable people?
Would an exacerbation of the individual’s illness-question the rational use of the weapon.
Is there a history or potential history (if the person is unknown to the trust) of the service user misusing weapons in the past?
Has the individual previously shared ideas or thoughts of injuring people in using any method?
Is the access to a weapon a new pattern of behaviour and associated with their symptoms of mental illness, for example, increasing level of paranoia.
Have the service user’s family or carers raised concerns about access to or storage of weapons?

11.6.5 No imminent public safety concern

If the team do not assess that a public safety issue exists at this point, then the following should be undertaken or considered:

formally risk assess the situation and include actions and decisions within clinical records
discuss any concerns and management arrangements with the service user
advise the service user on how they can gain advice or guidance on Safe management of their weapon
advise service user on why removal or disposal would be appropriate
for all firearms, prohibited firearms and offensive weapons the police should be informed. Staff should lead a discussion with the police concerning our need to maintain a relationship with the service user, and request sympathetic, but appropriate, action by the police which maintains a supportive role. This action is supported by the Data Protection Act and, or section 115 of the Crime and Disorder Act 1998
advise the service user on requirements regarding storage during community visits
continue to review risks associated with weapons
agree protective measures for future contacts, for example, Location of visits, numbers of staff to attend, etc.
place an alert/warning on the clinical records system

11.6.6 Public safety concern

If the team believe that a public safety issue exists, then it is clear that staff can and should share concerns with the police with the aim of:

clarifying the nature of weapons and their risk
providing formal guidance to the service user regarding storage or legality of ownership
facilitating potential removal
for mental health services, and where appropriate, developing use of multi-agency Public Protection Arrangements (MAPPA) processes
where possible or appropriate the service user or carer should be informed of the care- team’s concerns, and the requirement to inform the police for advice and guidance

The Information Governance of sharing information in this context is covered within the Data Protection Act and the Crime and Disorder Act (section 115). Both acts allow for such information to be shared between agencies. Further guidance can be sought from the Information Governance team.

The police will make a decision which will be based on the information provided and any other information available that is reasonable, proportionate and justifiable as to what action is required. Once the initial need has been identified to report to the police, a full discussion of the situation and clinical implication should be taken within a multi-disciplinary meeting. The risk management plan or care plan should be amended to take into account any newly assessed risks.

Note, staff must never handle or take possession of anything, which is or looks like a firearm. Staff should only take other weapons away from service users with their permission. Disposal of any weapons should be via the nearest local police station unless local agreements dictate another course of action.

11.6.7 Recording information

All actions, discussions and, or meetings will be recorded as soon as possible in accordance with trust standards on record keeping. The content of all informal discussions with the police will be logged by the police for audit and informing future risk assessments.

Within documentation the team needs to show that it has considered whether the availability of the weapons will or could constitute a public safety issue. As previously stated this relates to the risk that his individual may pose to others or them-selves and the risk the availability of the weapon by others may pose.

Issues to consider:

previous history of violence
previous history of using weapons
concerns for children and vulnerable adults who may be in the home or come into contact with the weapons
concerns from family or carers regarding a new and unusual interest in and, or collection of weapons
stability or mental health and symptoms associated with violence to self or others
evidence of substance misuse

11.6.8 Seeking advice or guidance

The identification of a public safety issue is not always easy or clear. It is recognised that teams may require assistance to make a decision that is rational and measured.

It is recommended that where different views are held by team members or the discussion is not clear then advice and guidance should be sought. This can include involvement of the police at an advisory level or provision of a legal opinion. On other occasions, it may be simply a case of accessing a third party opinion that will help add objectivity to the proceedings.

11.6.9 Potentially offensive weapon identified

11.6.9.1 Urgent action is required

Risk is very high:

move to a safe place
phone 999 immediately (or activate lone worker device if available) and provide the police with as much information as possible
inform line manager or manager on-call
complete a trust incident report
complete an entry in the service user record

11.6.9.2 Urgent action is not required

No obvious immediate risk:

consider discussion with service user
identify and record the situation in which the weapon was found
assess the current mental state of the service user who has access to the weapon, paying particular attention to any imminent risk factors associated with the weapon
convene a multi-disciplinary meeting, or at least speak to the team leader and colleagues
decide if there is a concern for public (or staff) safety and complete an entry in the service user record

11.6.10 Potentially offensive weapon identified

11.6.10.1 Public safety concern

If the team believe that a public safety issue exists, then it is clear that staff should share concerns with the police with the aim of:

clarifying the nature of weapons and their risk
providing formal guidance to the service user regarding storage or legality of ownership
facilitating potential removal
if MH-develop use of MAPPA processes
where appropriate the service user should be informed of the care- team’s concerns and the requirement to inform the police
complete an entry in the service user’s record

11.6.10.2 No public safety concern

If the team do not assess that a public safety issue exists:

formally risk assess the situation
discuss any concerns and management arrangements with the service user
advise the service user on how they can gain advice or guidance on safe management of their weapon
advise service user on why removal or disposal would be appropriate
for all firearms, prohibited firearms and offensive weapons the police should be informed
continue to review risks associated with weapons and complete an entry in the service user’s record

11.7 Appendix G Security of keys, fobs and access control systems

Staff emergency systems are a key part of measures which are in place to ensure the safety of staff, patients and visitors. They can provide an instant method of alerting staff that a potentially aggressive or violent situation or other emergency situation is occurring. They are utilised in ‘high risk’ areas where the patient group may be become abusive and violent.

A personal response device is intended to provide an alert in the vicinity of its activation. These devices should not be confused with lone working devices for which separate guidance is available.

The guidance below is provided to enable managers to introduce procedures to ensure that staff are aware of their roles and responsibilities in relation to staff emergency systems. The procedures should consider:

a system for controlling the distribution of personal response devices and other devices, such as two-way radios and pagers. This should include, but not be limited to:
unique numbering of each device
- how the devices will be stored
- who the devices will be issued to
- how a record will be made that a device has been issued. For example, the devices could be accessed from a key safe with a fingerprint reader which could also be used to control keys. In any event the record should include the name of the person, the date and the time of issue of the device(s)
- who will make checks at the end of each shift to ensure that devices have been returned, are in place and secure?
a process for ensuring that staff are familiar with how the system operates should be implemented and should be recorded as part of the induction. This should include, but not be limited to:
- how to activate a personal response device and what to expect when the system has been activated
- how to respond when the system is activated
- how to charge a device
- how to check the status of the batteries
- how to test the device
- how to clear the memory, if appropriate
- how to silence or reset the system
a system for testing all components of the staff emergency system should be introduced, this should include but not be limited to:
- battery checks on personal response devices on receipt of the device
- if appropriate, how often and when the system will be tested and who will test the system
a procedure for staff on how to respond to an emergency. This should include but not be limited to:
- consideration of the appropriate training that needs to have taken place
- consideration of the minimum number of staff to be able to effectively assist
- how to carry out a dynamic risk assessment, including the approach to an incident, what to look out for, what to listen for. Do not enter an area if you do not feel it is safe to do so, wait for a colleague
- in what circumstances do the police need to be contacted?
How to effectively contact the police using the ICII system, see below:
- 999 calls, be clear, be concise, be heard
- identity, where are you? Who are you phoning about? Who are you?
- capability, what is happening? Is there a threat to patients or staff or self or life?
- intent, has the person got weapons? What is the person doing? What is the extent of the incident now?
- immediacy, is there a threat to life? Is there a threat to property? Is there a threat to security?
a post incident procedure, this should include but not be limited to:
- submitting an incident report
- debrief and lessons learned for all staff
- consideration of counselling for staff

11.7.1 Security of keys

The trust has a duty to protect its service users, visitors and staff from harm, keep confidential and valuable information secure, and protect assets, property and possessions from damage and theft. An important tool in providing this protection is the control of entrances and exits.
The loss of a key, fob or swipe card can create risk by reducing security and so placing property, possessions or people at risk. The cost of replacing locks can also be substantial.

This guidance applies to any area within the trust which has a secure entrance or exit, and that entrance or exit is secured by a locking device which has a key, swipe card, electronic fob or other device for operating the lock. It also applies to secure locations within the trusts premises, such as safes, drug cupboards etc.

An effective monitoring and storage system for keys will ensure that security is maintained, whilst allowing entry to authorised personnel and providing a backup when entry is required out of the normal working function.

Areas with different needs will have local procedures. These areas should include those local procedures as attachments to this policy.

Access to a building out of normal working hours is typically gained by contacting a key holding company or obtaining keys form a 24 hour occupied area, for example Switchboard at Tickhill Road, Goldcrest Ward at Swallownest, Mulberry Ward at Great Oaks, Constant Security (key-holding for non 24 hour areas).

Where there is a key cabinet with multiple use of keys which are issued by staff, such as the Tickhill Road site, a key log book must be maintained to record the issue and receipt of keys. Security measures include:

storing all keys securely (whether in use, spare or master)
recording who keys are issued to, whether it is for short or long term use
recording when keys are returned to store
ensuring that electronic fobs, their control cards and unissued fobs, which are classed as keys, are stored securely and their issue and return is recorded
ensuring that any other devices which control the security of an entrance or exit are kept as securely as keys
reporting and investigating all losses of keys and breaches of security

Where there is a key cabinet with multiple use of keys which are issued by use of a combination of a personal PIN number and personal biometric information from an electronic key cupboard, the recording of the issue and receipt of keys is stored electronically and is available to system administrators.

11.7.2 Copying of keys

No key is to be copied by anyone without the permission of the director or head of service.

11.7.3 Loss of or theft of keys

Immediately a loss is noted, it is to be reported to the manager or head of service, security adviser, key custody staff and manager of the area the key concerns.
If a level one key (master or sub-master key) is missing then the relevant head of service is to be informed.
Outside normal working hours the duty manager, switchboard (for the Tickhill Road site) and security office (if there is one for the area) are to be informed.
An incident report is to be completed as well as any local reporting procedures that may be in place.
A decision of whether to replace the locks will be made and appropriate action taken.
If a level one key is missing, then a decision on what immediate security arrangements are necessary will be made.
Other electronic lock opening devices may have the ability to ‘decode’ a lost or stolen device or ‘recode’ all remaining devices. The decision on whether to decode or recode will be made by the relevant Manager in conjunction with the Safety team.

11.7.4 Combination locks (both digital and mechanical)

The number or entry code required to operate these locks should be seen to be as important as a key and kept as securely. However, there is much more chance of such a combination entering into the wrong hands.

Combinations are not to be:

issued to anyone who does not regularly work within the area.
written on notices or similar to be left on view.
easy to identify, such as a telephone number, or familiar date etc.

Combinations are to be:

changed as a minimum, every 6 months
changed as soon as it is believed they are compromised

It is recommended that combinations are changed when a member of staff leaves or a department relocates out of that area.

11.7.5 Electronic key cupboard or tracker systems

A variety of key control systems are available which monitor access and control withdrawal of key bunches. As a minimum, these systems must:

be located within a secure room
keep the key bunches individually secure within a locked cabinet
be able to identify the person removing the keys, either by biometrics or password or similar
allow the removal of only one bunch of keys designated to the person removing
record the date and time of removal and the identity of the person removing
record the date and time of return
allow checking of the keys’ physical presence
have a power loss protocol which maintains security

11.8 Appendix H Liaison with the police

Effective and regular liaison with the police through nominated routes will:

provide a consistent approach
encourage liaison
maintain effective contact in specific cases
allow for advice or guidance to be given in relation to specific cases
enable discussions about the levels of involvement of the organisations involved
enable the NHS Counter Fraud Authority (formerly NHS Protect) to be kept informed of progress of case being investigated by the police
develop the concept of mutual support in tackling crime within the NHS

11.8.1 Police liaison groups

The trust has the following committees and groups in place which involve formal liaison with the police, either at each meeting or as required (this list does not include local ad hoc meetings which may take place between specific trust units and local police, for example community police).

11.8.1.1 Multi-agency liaison meeting

This multi-agency meeting discusses Mental Health Act related issues, including where appropriate, liaison with the police relating to the Mental Health Act. These meetings also discuss the use of section 136 and 135 of the Mental Health Act, other relevant points concerning access to mental health services and general security issues which affect the local communities and, or the justice system. The police represent South Yorkshire, and act as liaison with North Lincolnshire as required. Other agencies invited include local A and E departments, ambulance service and trust managers.

11.8.1.2 Audit committee

The counter fraud specialist will liaise with the police as and when required, on behalf of the trust and will keep the SMD and audit committee up to date on any issues or investigations.

In accordance with the joint working agreement between the association of chief police officers, the Crown Prosecution service and the NHS Counter Fraud Authority, the trust will seek regular liaison with designated police officer representatives.

The LSMS will act as the first point of liaison and single point of contact for the trust if a specific suitable contact cannot be identified. The LSMS will be able to direct the police to a suitable contact or, if necessary, act as the liaison for that particular incident.

The details of the designated police officers will be held and maintained by the LSMS.

11.8.1.3 Serious incidents

The incident management policy outlines the reporting, recording and investigation procedures which are to be followed when a serious incident occurs.

A serious incident is defined as an incident that occurred in relation to NHS-funded services and care resulting in one of the following:

unexpected or avoidable death of one or more patients, staff, visitors or members of the public
serious harm to one or more patients, staff, visitors or members of the public or where the outcome requires life-saving intervention, major surgical or medical intervention, permanent harm or will shorten life expectancy or result in prolonged pain or psychological harm (this includes incidents graded under the NPSA definition of severe harm)
a scenario that prevents or threatens to prevent a provider organisation’s ability to continue to deliver healthcare services, for example, actual or potential loss of personal or organisational information, damage to property, reputation or the environment, or IT failure
allegations of abuse
adverse media coverage or public concern about the organisation or the wider NHS
one of the core set of 25 ‘never events’

All members of staff are required to report serious incidents to their manager immediately. Following a reported incident the manager must assess the environment, risk to patients and staff, seek relevant professional advice and ensure that appropriate action is taken.

Where the appropriate action includes contacting the police, and if the police confirm the need for continuing involvement, the manager is to work with the police with regard to the management and, or investigation of the incident.

In situations where the police have been contacted, the manager is to ensure that the LSMS has been notified via the Safeguard electronic incident reporting system.

All victims of an alleged crime have the right to pursue prosecution and managers must ensure that individuals are aware of such rights. Where an incident involves a service user(s) the manager and registered medical practitioner will liaise with the police in respect of statements and consent or capacity issues.

The registered medical practitioner has key responsibility, in consultation with the clinical team, for the safe, future management of the individual and must be involved in decisions relating to the criminal justice system.

11.8.2 Specific incidents

11.8.2.1 Missing patients

The trust has a policy for patients missing or absent without leave (AWOL) policy which details actions to be taken, including contacting the local police as soon as possible if the missing patient is detained under the Mental Health Act, deemed to be a danger to themselves or others, or not thought to be capable of taking care of themselves. The police are to be offered every assistance, including a description of the person, what, if any, risk they present and any likely locations. Refer to the patients missing or absent without leave (AWOL) policy for further information.

11.8.2.2 Safeguarding children

The duty of all staff to safeguard and promote the welfare of children and the procedures to be followed if staff suspect child abuse or neglect are detailed in the local safeguarding children boards (LSCB) procedures relevant to the geographical area in which the trust provides services and in the trust’s safeguarding children policy.

In certain cases there may be police involvement in safeguarding children processes and if required, the trust will liaise closely in social services and the police and follow their advice or guidance.

The trust board lead for safeguarding children will maintain an overview of all cases.

11.8.2.3 Safeguarding adults

The responsibility of all staff in relation to the protection of vulnerable adults form abuse is outlined in the safeguarding adults policy and procedures relevant to the geographical area in which the trust provides services.

The procedure makes it clear that if a crime is suspected or has occurred the senior manager should contact the police for consultation, advice and, or identifying individuals. The decision about whether contact with the police is simply for consultation, advice or information or an actual referral will be made by the senior manager. It is the job of the police to investigate crime. The consultation with the police is usually the first strategy discussion if a crime is involved and will lead to a decision about who will investigate if an investigation is needed. The trust will liaise closely with the police and follow their advice or guidance.

The trust board lead for safeguarding adults will maintain an overview of all cases.

11.8.2.4 Counter fraud or fraud

The trust’s counter fraud, bribery and corruption policy sets out the responsibilities of staff and the action that should be taken whenever a case of fraud, bribery or corruption is suspected within the Trust.

The counter fraud specialist is responsible for undertaking the appropriate investigation in accordance with the NHS Protect Standards for Providers and the NHS Executive Counter Fraud Specialist will present a report to the SMD and recommend whether or not the case is suitable for prosecution.

The counter fraud specialist is then required to consult with NHS Protect and the Area Anti- Fraud Specialist before referral to the Crown Prosecution service (CPS). The area anti-fraud specialist will decide on the suitability of further criminal investigations.

It is the responsibility of the area anti-fraud specialist to contact the CPS in cases of fraud, bribery and corruption.

If prosecution is to be progressed the counter fraud specialist will manage the prosecution process and liaise with the CPS

11.8.3 Section 136 Mental Health Act

The police have specific responsibilities under the Mental Health Act 1983. These responsibilities include the police power to remove an individual to a place of safety (section 136 of the Act). The purpose of removing a person to a place of safety is to enable them to be examined by a doctor and interviewed by an approved mental health professional and for any necessary arrangements for care and treatment to be made. Local social services, the trust and chief Constable are required to establish a clear policy for use of the power. The section 136 of the mental health act 1983 policy outlines the agreed arrangements.

11.8.4 Multi agency public protection arrangements (MAPPA)

The principle responsibility for protecting the public from sexual and violent offenders rests with the criminal justice agencies. However, the effectiveness of public protection often depends on more than just a criminal justice response and other agencies, including the trust, also play an important role in the management of risk form these offenders: especially in relation to child protection and domestic violence which require multi-agency joint working.

The purpose of the cooperation therefore is:

to cooperate the involvement of different agencies in assessing and managing risk
to enable every agency which has a legitimate interest to contribute as fully as its existing role and function s require in a way that complements the work of other agencies

The trust has signed a memorandum defining the duty to co-operate and this includes a protocol for information sharing in respect of patients who are ex-offenders and live in the community. The trust will, in the course of this work, link with the police public protection Units in the relevant geographical areas. The care group directors have overall responsibility for MAPPA arrangements within the trust.

11.8.5 Non multi agency public protection arrangements (non-MAPPA)

In accordance with home office guidance, a separate set of arrangements exist to manage individuals who do not have convictions or who do not have ‘relevant’ convictions under schedule 15 section 224 of the Criminal Justice Act. These arrangements are referred to as Non-MAPPA and enable any agency to refer an individual to the police for consideration of multi-agency risk management. Meetings held under these arrangements are called special case conferences. The trust will cooperate fully with the police with regard to Non-MAPPA processes.

11.8.6 Specialist drug Intervention and prolific offender programmes

Specialist drug interventions programmes have been established funded by the home office but working in conjunction with drug treatment service providers (including the NHS).

Under the Drugs Act, individuals can be required to undertake drug testing in police premises and, dependent on the outcome, attend for ‘required assessment’. There is an expectation that information on compliance or otherwise will be shared between the treatment provider and the police. As part of the enforcement aspect of these provisions, a police officer may in some situations be seconded to drug treatment services. Localised arrangements are in existence for the cover of information sharing etc.

11.8.7 Disclosing Information to the police or Justice Department

As with any general disclosure of information, requests from the police or court are dealt with by the Information Governance team. Staff must not feel pressured or intimidated into giving information just because the police have requested it. Information can only be released if the service user or employee has given their consent or with a court order or the request is made under the Prevention of Terrorism Act.

Reference should be made to the trust’s information governance policy and management framework (includes data protection policy content) for more information, contact the Information Governance team.

In certain circumstances an individual’s right to confidentiality may be overridden by the public’s interest in having access to information. Decisions to disclose such information must be discussed with the Information Governance team (or duty manager if out of hours). The decision made must be recorded in the relevant file (for example, health record or personnel file) and the reasons justifying the action taken.

If a service user is taken into custody or appears in court, information may need to be exchanged. This may be necessary to ensure that those who need care receive it and that the criminal justice authorities can take the individual’s health (including mental health) into account in determining the appropriate outcome.

Requests for CCTV images are processed by the Safety team or the Information Governance team and are not to be released without their approval.

Document control

Version: 8.1.
Approved by: Corporate policy approval group.
Date approved: 20 May 2021.
Name of originator or author: Safety team or head of estates and facilities.
Name of responsible individual: Health, safety and security forum or director or nursing and allied health professions.
Unique reference number: 224.
Date issued: 7 March 2023.
Review date: June 2024.
Target audience: All staff.

Page last reviewed: April 26, 2024
Next review due: April 26, 2025

Feedback

Report a problem

Contents