Contents
1 Introduction
It is the trust’s aim to support and accommodate visitors wherever possible whilst upholding the trust’s responsibility to protect the safety, security, privacy and dignity of patients, relatives, friends, carers and staff. This document explains the procedure that needs to be followed when organising any such visit to all areas of the trust.
The trust cares for many vulnerable patients or service users and therefore has a duty to safeguard them from any form of abuse or psychological grooming. Therefore this policy has taken into consideration the recommendations arising from the Lampard report “themes and lessons learnt from NHS investigations into matters relating to Jimmy Savile’.
The trust also recognises the need to ensure that any visits do not have a detrimental effect on the provision of clinical services and takes practical steps to organise and manage arranged visits with the minimum disruption to the high quality care provided by trust staff.
1.1 Definitions
| Term | Definition |
|---|---|
| A VIP (very important person) | could be a celebrity, senior politician (for example, minister) members of the Royal family. VIP can mean any dignitary who requires special treatment. Within the trust it may be someone who is adding profile to an appeal or service |
| Celebrity | Famous high profile figure from, sport, television, film, music, and so on, who may be well known to the public. It may also include costume characters who could be known to children and young people |
| A governor | Could be a patient or service user, carer, a member of the public or a representative from a partner organisation. Visits to services are one of the most effective ways in which governors can get to know the trust by talking to staff, service users or patients and carers and finding out what happens there. Although visits are not a defined role of a governor, these can add immeasurably to their understanding of the trust and its staff and patients |
2 Purpose
The purpose of this policy is to ensure there is a framework in place to arrange and manage planned visits for VIP’s or celebrities and governors. These visits may involve access to a range of services and facilities across the trust including; inpatient services, community settings and corporate services and facilities
Additionally it will ensure that the risk to the safety and security of patients and staff arising from VIP visits to the trust is minimised and that a process is in place for reviewing visits that have taken place. The policy also sets out how an unannounced visit should be dealt with.
3 Scope
This policy applies to all trust staff across all services and teams who may be involved in organising or hosting a visit by a VIP, celebrity or a governor to any of the trust’s services or facilities.
4 Responsibilities, accountabilities and duties
4.1 Chief executive (CEO)
The chief executive has overall accountability for ensuring high quality provision, safe and effective services within the trust and delegates the responsibility for visits to directors and deputy care group directors.
4.2 Director of nursing and quality
The director of nursing and AHPs is the designated director and trust lead for safeguarding and will assist directors or deputy care group. Directors, corporate or service managers with any safeguarding issues associated with any visits arranged.
4.3 Chief operating officer
The chief operating officer is responsible for overseeing the implementation of the policy.
4.4 Care group directors
Care group directors are responsible for implementing this policy and have a delegated responsibility to ensure the procedure is known to all staff and that they adhere to it.
4.5 Board secretary
The board secretary is responsible for the dissemination of this policy and to oversee its implementation.
4.6 Head of patient, engagement and experience
The head of patient engagement and experience will have oversight of the dissemination and implementation of this policy.
4.7 All staff
All staff are responsible for adhering to the procedures set out in section 5 of this policy.
4.8 Membership and engagement facilitator
The membership and engagement facilitator is responsible for working with the services to organise the governor visit to ensure it is safe and successful.
4.9 Head of communications or Communications team
The head of communications and the team are responsible for working with services to organise the visit for VIP’s and celebrities to ensure the visit is safe and successful.
4.10 Events coordinator
The events coordinator will work with the Head of Communications to organise the visit for VIP’s and celebrities to ensure the visit is planned and coordinated.
5 Procedure or implementation
5.1 Obtaining agreement for a visit
The policy requires that official visits are always formally approved, and visitors are accompanied throughout the visit to the trust.
5.1.1 VIP, celebrity visits and governor visits
For planned VIP, celebrity and governor visits the chief executive is the first person to be notified of the request and would authorise consent to the visit.
Once the visit has been approved, the head of communications (for VIP’s and celebrities) or membership and engagement facilitator (for governors) should approach the relevant care group who will work with them to arrange the visit. The care group or corporate services director will then discuss this with the service to ensure that the visit is appropriate.
5.2 Planning the visit
Once a visit has been approved, the visit host (for example, care group director, deputy care group director, corporate heads of service or nominated individual) will work with the head of communications (for VIPs, celebrities and governors) membership and engagement facilitator (there should be no more than 2 visitors attending at any one time) to arrange the visit and complete the following:
- if it is considered necessary, draft a programme for the visit, including timings and format or route
- identify the number of visitors and determine that it is appropriate, ie, usually no more than two visitors. For any visits proposing more than two a specific discussion should be held with the care group director
- the host will conduct a risk assessment to identify and mitigate any possible issues around privacy and dignity, safeguarding and confidentiality
- this is to ensure VIP’s, celebrities or governors do not compromise patient care, unduly inconvenience staff or patients or breach patient confidentiality
The trust follows the government DBS eligibility guidance tool (opens in new window) to ensure that we meet the appropriate regulations and can only undertake DBS checks for staff employed by the trust or volunteers (governors) who would undertake regulated activities with patients. Visiting would not be classed as a regulated activity. As the majority of VIP or celebrity) visits to the trust are “one off” events a disclosure and barring (DBS) check is not required, therefore the approved visitor(s) must be accompanied at all times.
- All trust governors have a DBS check.
- Inform relevant colleagues of the visit. This may also include the trust security advisor, who, if appropriate will undertake a risk assessment to determine the appropriate level of additional resources or control measures that may be required. Risk assessments should include the likelihood of uninvited photographers and fans who are attracted by the presence of a VIP or celebrity.
- The Logistics team will organise parking arrangements and cordon off any areas.
- The events coordinator (VIP’s or celebrities) or membership and engagement facilitator (governors) will arrange the welcome and who will accompany the visitors (designated chaperone) at all times while on trust premises. To ensure adequate supervision is maintained at all times the number of visitors will be restricted, usually no more than two visitors. For any visits proposing more than two visitors, permission should be sought from the care group director in advance of the visit.
- For VIPs:
- the head of communications or events coordinator will work with other organisations, if relevant, regarding the visit arrangements for example, Buckingham Palace or the Department of Health
- the events coordinator will make arrangements for hospitality (any refreshments required)
- the events coordinator will work on an appropriate invitation list
The care group director (or nominated individual) will identify patients who will be involved in the visit, gaining their consent (or guardian’s consent dependent on patients’ status and capacity) to be involved. The consent process will explain the nature of the visit and what to expect. If there is likely to be photographs the patient will be asked if they consent to being photographed and will be asked to sign a consent form which will be stored in their clinical records.
- The head of communications will arrange VIP’s photographs and, or media calls if appropriate or required.
- If the care group director (or nominated individual) considers it inappropriate for the visit to go ahead due to a clinical need or risk, for example then the visit may be cancelled, even on the day.
5.3 Prior to the visit
Prior to the visit all approved VIPs, celebrities and governors should be briefed with regard to safeguarding procedures, infection prevention and control, privacy and dignity and the expected standards of behaviour policies and procedures required during the visit where appropriate, by the visit organiser.
5.4 During the visit
Upon arrival at trust premises, All visitors will be met by a member of staff which may be a clinical leader, manager or executive director. The member of staff will ensure the visitor is logged with the Communications team (VIPs or celebrities) or the membership and engagement facilitator (governors) and that a visitor badge is issued.
VIPs or celebrities and governors must be accompanied at all times by the designated chaperone, who will stay with them from the time they enter the trust site to the time they leave the site. They should not have access to treatment or bathroom areas or observe any intimate care.
The agreed programme for the visit should be adhered to as closely as possible. This includes only meeting or visiting patients who have already given consent to meeting VIP’s, celebrities or governors. This may be essential for a variety of reasons including security.
VIPs or celebrities and governors should be briefed with regard to safeguarding procedures (refer to safeguarding adult policy and safeguarding children policy), infection prevention and control (for example, bare below the elbows: refer to standard precautions policy, eliminating mixed sex accommodation and maintaining privacy, dignity and respect policy and the expected standards of behaviour required during the visit where appropriate, by the visit organiser.
If media are present for a VIP or celebrity visit a member of the Communications team will accompany them at all times while on trust premises.
If a trust spokesperson is required for the media, they will have been briefed in advance on the visit or topic of interview by the head of communications.
5.4.1 Reporting concerns
If during any visit, the behaviour of the visitor gives cause for any concern for example causing upset or distress to patients it should be brought to the attention of the chaperone and the visit brought to an end immediately.
In the event of a serious incident, follow the serious incidents policy or contact the head of patient safety for advice.
5.5 Following a visit for a VIP or celebrity
The Communications team will write, seeking approval for a press release (if required) and monitor media coverage of the visit.
The visit host will draft a thank you letter to the VIP or celebrity for the visit. This will be shared with the relevant care group director and CEO or chair, if appropriate.
A debrief will take place with the staff involved in the visit. Shared learning from this debrief should extend across all staff within the trust to prepare staff for future visits to their service, area or department.
5.6 Unannounced visits
If a VIP or celebrity or governor attempts to undertake a visit without any prior notice, the person in charge of the clinical area should be immediately contacted, they will speak to the people attempting to visit and will deny them access. Within office hours the Communications team or membership and engagement facilitator or head of patient engagement and experience must be notified immediately. The visitor should be kept in the reception or the ward nursing station until a member of the Communications team or membership and engagement facilitator or head of patient engagement and experience arrives.
If the attempted visit occurs outside normal working hours and especially at weekends, the person in charge of the clinical area should contact the on-call manager for advice. The visitor(s) should be denied access and asked to wait in the reception until a senior member of staff is available.
6 Training implications
6.1 How to implement this policy
Staff will be made aware of this policy through daily communications and monthly edition of trust matters, which is communicated electronically. All care group directors, care group nurse directors, deputy care group directors, head of corporate services managers or modern matrons need to ensure the policy is explained at team meetings. Those who manage staff on ward areas and those without access to a computer should make them aware of this policy.
6.2 Training needs
There are no specific training needs in relation to this policy, but the following staff will need to be familiar with its contents: head of communications, Communications team, board secretary, membership and engagement facilitator, director of nursing and AHPs quality, head of patient engagement and experience and events coordinator.
As a trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through this policy. If they need support they can ring either the Communications team (VIP or celebrity) or the membership and engagement facilitator (governors).
7 Monitoring arrangements
7.1 The visit
- How: Communication team (VIP or celebrity) or foundation trust office (governors).
- Who by: Head of communications or board secretary (VIP or celebrity) membership and engagement facilitator or board secretary (governors).
- Reported to: Care group director or director of strategy and staff member who arranged visit.
- Frequency: As required.
The Communications team and the membership and engagement facilitator will ensure the policy is adhered to. After each visit, the Communications team (VIP or celebrity) or membership and engagement facilitator (governors) will arrange a debrief with staff involved to see what went well or what could have gone better in a bid to improve future visit experiences.
Shared learning from this debrief will extend across all staff groups via the trust organisational learning networks, this will support staff with future visits to their service area
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
Any patients involved in governor visits should have given consent prior to the visit via the manager of the ward or service
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 for 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).
Anyone involved in a governor visit will have given consent (if possible) prior to the visit. If they are not capable of giving consent, they will not be part of the visit unless their guardian has granted the consent.
9 Links to any other associated documents
This policy links with the following documents:
- Code of conduct for governors (section 8)
- Maintaining privacy and respect policy
- Safeguarding adults policy
- Safeguarding children policy
- Standard precautions policy
- Standards of business conduct policy
- Information governance policy
- Eliminating mixed sex accommodation and maintaining privacy, dignity and respect policy
10 References
- Lampard report Themes and lessons learnt from NHS investigations into matters relating to Jimmy Savile (February 2015).
11 Appendices
11.1 Appendix A Flowchart
- VIP, celebrity and governors will contact the trust to discuss potential areas of interest, services and facilities to visit.
- Membership and engagement facilitator (governors), head of communications (VIPs) to make contact with care group director or corporate services directors to outline the request of the visit.
- Care group director will discuss with the service if the visit is appropriate or not and the designated host.
- The host will work with the head of communications and events coordinator(for VIPs and celebrities) or engagement facilitator(for governors) to arrange visit.
- The host will draft a programme for the visit including the time and format.
- The host will conduct a risk assessment to identify and mitigate possible issues around privacy and dignity, safeguarding and confidentiality.
- All colleagues are informed of the visit.
- Where patients are to be involved in the visit the host will gain consent(guardian’s or carer’s consent).
Document control
- Version: 3.1.
- Unique reference number: 33.
- ratified by: Corporate policy approval group.
- Date ratified: 29 January 2024.
- Name of originator or author: Head of communications or membership and engagement facilitator.
- Name of responsible individual: Executive director of nursing and allied health professionals.
- Date issued: 31 January 2024.
- Review date: October 2024.
- Target audience: All staff.
Page last reviewed: April 30, 2024
Next review due: April 30, 2025