Executive Director of Nursing and Chief Operating Officer. Lead Officer. Tony Gray Head of Safety, Security and Resilience

Transcription

1 Document Title Security Management Policy Reference Number Lead Officer Executive Director of Nursing and Chief Operating Officer Author(s) (name and designation) Ratified By: Tony Gray Head of Safety, Security and Resilience Business Delivery Group Ratified Date: December 2017 Implementation Date December 2017 Date of full implementation December 2017 Review date December 2020 Version V04 Version Type of change Date Description of change Review and Amendment Log V04 Review Dec 17 Policy Review This policy supersedes, which should now be destroyed: V03.9 Reference Number Title Security Management Policy

2 - Security Management Policy Section Contents Page No: 1 Introduction 1 2 Purpose 1 3 Duties and Responsibilities A professional approach to managing security in the NHS 2 4 Access to Security Management Advice 5 5 Development of Practice Guidance Notes 5 6 Consultation and communication with stakeholders 5 7 Approval and review of Document 5 8 Definitions of Terms used 6 9 Equality Impact Assessment 6 10 Training 6 11 Implementation 7 12 Monitoring and Compliance of Security Management Policy and Practice Guidance Notes 7 13 Monitoring Compliance 7 14 Standards/ Key Performance Indicators 7 15 Fraud and Corruption 7 16 Fair Blame 7 17 Associated documentation 8 18 References 8 Standard Appendices A Equality and Diversity impact Assessment Form 9 B Communication and Training Needs Information 11 C Monitoring Tool 13 D Policy Notification Record Sheet - click here

3 Practice Guidance Notes (PGNs) listed separate to policy U/D = under development PGN Number Title Issue SM-PGN 01 Closed Circuit Television Systems Date Issued Review Date V03- Issue 8 Dec 17 Jun 18 SM PGN 02 Lone Working V03- Issue 7 Dec 17 Jun 18 SM PGN 03 Use of Mobile Comm. Devices V02- Issue 5 Nov 17 May 18 SM PGN 04 Nuisance and Malicious Calls V03- Issue 6 Dec 17 Jun 18 SM PGN 05 Counter Terrorism Response V01- issue1 Sep 17 Sep 20 SM-PGN-06.1 Joint Missing Persons Guidance 3 Sep 17 Mar 19 SM PGN 07 Staff Support for the Deterrence, Prevention, Detection and Investigation of Physical and Non-Physical Assaults included within SM-PGN-11 SM PGN 08 Trust Search Dog Procedure V02- Issue 1 Sep 17 Feb 20 SM-PGN-09 Identicom Lone Worker Protection System V02- Issue 8 Dec 17 Jun 18 SM-PGN-10 Hospital Lockdown in Emergency situations V02- Issue 8 Dec 17 Jun 18 SM-PGN-11 Working with Police and Criminal Justice System-replacing Management of Offences V03- Iss 2 Sep 17 Oct 19 SM-PGN-15 NEW - Guidance on the aftercare with the use of Taser, CS Incapacitant Spray (CS) and PAVA Incapacitant Spray (PAVA) 3 Sep17 Feb 18 SM-PGN-16 Covert CCTV Recording U/D

4 1 INTRODUCTION 1.1 Security Management has undergone a number of changes at a national level and now the remit sits with individual boards and local commissioning arrangements. 1.2 This document defines the policy and practice guidance notes to be followed within the (the Trust) for all aspects of Security Management. 1.3 The Trust will work with the other agencies to tackle security management issues across the NHS through a range of generic actions: Creating a pro-security culture. Deterring those who may be minded to breach security. Preventing security incidents or breaches from occurring. Detecting security incidents or breaches. Investigating security incidents or breaches. Applying sanctions against those responsible for security incidents or breaches. Seeking redress through criminal and civil justice systems from those responsible for security incidents. 1.4 All staff working within the Trust have a responsibility to ensure they work in a safe manner and must familiarise themselves with the correct procedures contained in this document. Those in charge of wards and departments are responsible for ensuring that their staff, especially new starters, locum and agency staff, follow Practice Guidance Notes (PGNs) within this policy document. Copies of the policy document will be available in all wards and departments. 1.5 The procedures also apply to medical staff, nursing staff and other types of staff from other NHS Trusts or from private practices, who are contracted to work in the Trust on a sessional basis. Managers who contract for these services must make it explicit within the written contract that these sessional staff must follow the procedures described. 1.6 The concepts of patient safety, focussed care and patient empowerment provide a fresh approach to some long-established practices. Similarly, the principles of Risk Management, which are high on the Trust s agenda, are embodied in the procedures herein. 2 PURPOSE 2.1 The Trust places the health, safety and welfare of its patients, carers, staff and visitors high amongst its priorities and will ensure it maintains safe and secure conditions throughout the organisation. It will work closely with partner organisations where the health, safety and welfare have shared ownership, to ensure co-operation at all levels. 1

5 2.2 The relevant primary legislation concerning these functions are: The Health and Safety at Work etc. Act 1974 The Management of Health & Safety at Work Regulations (as amended) The Policy is also based on the recommendations and requirements of historical but still current Security Management documents, these will be updated as new guidance is issued or replaced: A Professional Approach to Managing Security in the NHS. Tackling Violence Against Staff. Non Physical Assaults Explanatory Notes Not Alone A Guide for the Better Protection of Lone Workers in the NHS. Safe & Se(cure) - How You Can Help the NHS Protect Itself. NHS Security Manual. 2.4 The Trust requires all staff to have a working knowledge of this policy and to be familiar with above listed rules and guidelines. Information, including updates will be available via Local Security Management Specialists (LSMS). In addition to this information will be shared via the Health, Safety and Security Group. 2.5 Staff are personally accountable for their practice and in the exercise of their professional accountability must Act always in such a manner to promote and safeguard the interests and well being of patients. Ensure that no act or omission on their part or within their sphere of responsibility is detrimental to the interests, condition or safety of patients, staff and visitors. Maintain and improve their professional knowledge and competence. Acknowledge any limitations in their knowledge and competence and decline any duties or responsibilities unless able to perform them in a safe and skilled manner. 3 DUTIES AND RESPONSIBILITIES - A Professional Approach to managing Security in the NHS 3.1 Chief Executive The Chief Executive on behalf of the Trust retains ultimate accountability for the Health, Safety and Welfare of all patients, carers, staff and visitors however key tasks and responsibilities will be delegated to individuals in accordance with the content of this policy. 2

6 3.2 Executive Director of Nursing and Chief Operating Officer The Executive Director of Nursing and Chief Operating Officer in their capacity as the Trust s Security Management Director shall assume responsibility on behalf of the Board of Directors for all aspects of Security Management within the Trust. They will ensure that all management arrangements are in place to ensure compliance with this policy. 3.3 Board of Directors The Board of Directors will create challenge based on the security related reports received at board. 3.4 Head of Safety & Security The Head of Safety and Security shall ensure all security provisions are administered in line with all other Trust policies and will liaise with all clinical specialities to ensure that the Trust can comply with all its responsibilities. 3.5 Locality Care Group Directors It will be the responsibility of Locality Care Group Directors to own and action any Group based recommendations, which are in relation to security management. Where necessary Locality Care Group Directors will provide any necessary resources including management support, which may be needed to mitigate any security management risks. 3.6 Local Security Management Specialist s (LSMS) As part of the Security Management every Trust must appoint an individual to assume the day to day responsibility of security management to assist the Security Management Director to implement all aspects of security provision within the Trust. For the purpose of this policy and all Trust practice guidance notes (PGNs) the Trust s Local Security Management Specialists shall assume this responsibility and assist the Security Management Director to comply with all Security Management Standards The Trusts Local Security Management Specialist s will: Maintain their Security Management competency Undertake security management work in accordance with any legal framework and the NHS Security Management Manual Carry out Security Risk Assessments both in a pro-active manner to prevent security incidents or breaches and re-actively following reported security incidents and produce recommendations and guidance for improvements Chair the Trusts Health, Safety and Security Group. Be a central link for all security issues across the organisation Be the Single Point of Contact (SPOC) for security management 3

7 Monitor police investigations and update the member of staff and the Trust on progress Ensure details of incidents are recorded on the Trust System # ;/Produce an annual report on security management for assurance and present to the Board of Directors 3.7 Security Risk Assessments The Trust carries out security risk assessments in a number of different ways and for a number of different reasons. Security risk assessments carried out pro-actively as part of new project design, will be captured in the design specifications of buildings, and will include such things as CCTV, Access / Egress control, staff attack systems, security lighting etc. Security risk assessments carried out as part of general risk assessments through group risk register activity, this information and the resultant actions will be managed through the groups, and reported through their quality and performance groups. Re-active security risk assessments following incidents, complaints and claims. These will be fed into the groups and also where appropriate through to the Business Delivery Group. This will be dependant on escalation of risk Action Plans From the above information there will be a number of action plans created to fulfil the requirements of each of the above assessments. Action plans can be in the form of individual specifications drawn up for provision of new security equipment such as CCTV. Action plans can be in the form of minutes from groups or committees, with identified leads. Action plans created as a result of risk register activity. Action Plans can be as result of findings from Incidents, Complaints and Claims. 3.8 Head of Estates & Facilities As part of this policy the Head of Estates & Facilities shall ensure the effectiveness of day-to-day security provision across the Trust and take on board all aspects of the Security Management standards. 3.9 Health, Safety and Security Group The responsibilities of the above are identified in the Terms of Reference (Appendix 1) at the end of this policy. 4

8 4 ACCESS TO SECURITY MANAGEMENT ADVICE 4.1 In the first instance all staff should access any advice about Security Management strategic issues from the Trust s Local Security Management Specialist. In absence of this then advice should be sought from the Security Management Director. For contact details see Appendix For day-to-day operational security issues Facilities Management should be contacted. 5 DEVELOPMENT OF PRACTICE GUIDANCE NOTES 5.1 The Local Security Management Specialists will develop specific practice guidance notes to cover immediate risk issue areas. 5.2 Practice guidance notes will also be developed to reflect the standards of the NHS Security Manual if Trust policies or processes do not already cover these areas. 6 CONSULTATION AND COMMUNICATION WITH STAKEHOLDERS 6.1 This is an existing policy with additional / changed content that relates to operational and / or clinical practice and was therefore circulated to the following for a four week consultation period: North Locality Care Group Central Locality Care Group South Locality Care Group Corporate Decision Team Business Delivery Group Safer Care Group Communications, Finance, IM&T Commissioning and Quality Assurance Workforce and Organisational Development NTW Solutions Local Negotiating Committee Medical Directorate Staff Side Internal Audit 7 APPROVAL AND REVIEW OF DOCUMENT 7.1 This policy is approved by Business Delivery Group and will be reviewed 3 years from date of issue, unless by exception, i.e. due to change in legislation or standards etc. 7.2 The Trust Health, Safety and Security Group as part of its Terms of Reference will have responsibility to review the Security Management Arrangements on behalf of the Trust and provide assurance to the Quality and Performance Committee. 5

9 8 DEFINITIONS OF TERMS USED LSMS PGN SMS SPOC Local Security Management Specialists Practice Guidance Note Security Management Specialist Single Point of Contact Security Risk Assessment A security risk assessment is a proactive or re- active assessment in line with the guidance offered by NHS Protect carried out by an accredited local security management specialists 9 EQUALITY AND DIVERSITY ASSESSMENT 9.1 In conjunction with the Trust s Equality and Diversity Officer this policy has undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. 10 TRAINING (See Appendix B 10.1 Preventing security incidents, loss, criminal damage and violence and aggression towards staff, patients and others is a Trust priority. By providing the appropriate security management training the Trust seeks to: Ensure violence and aggression is managed appropriately and in line with Trust expectations. Ensure appropriate sanctions are sought where criminal activity has taken place within the Trust. Develop a positive security management culture within the Trust. Develop clear lines of communication in relation to security management, including the development of inter-agency groups. Meet its legal duty to protect the health and safety of staff. Ensure advancements in technology are considered as part of security management risk controls. Undertake comprehensive risk assessments around the protection of property and assets as well as the security of Trust premises To this end the Trust will provide Security Management awareness training as part of the Statutory and Mandatory Training arrangements Levels of training are identified in the training needs analysis and are included within the Training Guide which can be accessed via this link 6

10 11 IMPLEMENTATION 11.1 Managers at every level are expected to implement the requirements contained within this policy in conjunction with their risk management arrangements. Those arrangements include hazard identification, ensuring remedial action, monitoring and review of their safe systems of work This will be monitored at the respective Locality Care Group Quality Meetings. 12 MONITORING AND COMPLIANCE OF THE SECURITY MANAGEMENT POLICY AND PRACTICE GUIDANCE NOTES 12.1 There are a number of ways in which the compliance to this policy and practice guidance notes will be monitored (see Appendix C Audit Monitoring Tool). 13 MONITORING COMPLIANCE 13.1 Security Management will be monitored on an annual basis the Health, Safety and Security group, Audit Committee based on internal audits and by external agencies such as Health & Safety Executive and Care Quality Commission. 14 STANDARDS/KEY PERFORMANCE INDICATORS 14.1 Care Quality Commission Fundamental Standards 14.2 NHS Resolutions - Guidance 15 FRAUD AND CORRUPTION (Only if appropriate) 15.1 In accordance with the Trust s policy NTW(O)23 Fraud and Corruption/Response Plan, all suspected cases of fraud and corruption should be reported immediately to the Trust s Local Counter Fraud Specialist or to the Executive Director of Finance. In some circumstances a Security Management incident may include elements of Counter Fraud, and vice versa. Where this is the case there must be robust communication between Local Security Management Specialists (LSMS) and Local Counter Fraud Specialists (LCFS) Where information regarding fraud and security is released as an alert, the alert protocol, Appendix 4, will be completed by either the LSMS or the LCFS and shared respectively. 16 FAIR BLAME 16.1 The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken. 7

11 17 ASSOCIATED DOCUMENTATION NTW(O)01 - Development and Management of Procedural Documents NTW(O)05 Incident Policy and Practice Guidance Notes - Security Management Policy Practice Guidance Notes 18 REFERENCES The Health and Safety at Work etc. Act 1974 The Management of Health & Safety at Work Regulations (as amended)

12 Appendix A Names of Individuals involved in Review Equality Analysis Screening Toolkit Date of Initial Screening Review Date A Gray Dec 17 Dec 2020 Trustwide Service Area / Locality Policy to be analysed Security Management Policy V04 Is this policy new or existing? Existing What are the intended outcomes of this work? Include outline of objectives and function aims To define the standards and responsibilities in respect of security management and legislative compliance. Who will be affected? e.g. staff, service users, carers, wider public etc staff, service users, carers, wider public Protected Characteristics under the Equality Act The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them Disability Sex Race Age Gender reassignment (including transgender) Sexual orientation. Religion or belief Marriage and Civil Partnership Pregnancy and maternity Carers Other identified groups How have you engaged stakeholders in gathering evidence or testing the evidence available? As part of security incident reporting we see no impact on any group with a protected characteristic. NTW(0)21 Security Management Policy V04 Dec 17 9

13 How have you engaged stakeholders in testing the policy or programme proposals? As part of original consultation, no change to impact. For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs: All Trust staff through original consultation Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life. on any group from the implementation of this policy. Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic Eliminate discrimination, harassment and victimisation Standard approach to work. Advance equality of opportunity Promote good relations between groups What is the overall impact? Standard approach to work. Standard approach to work. Compliance with this policy should ensure any issues of discrimination or lack of equality are identified in security incidents and appropriate action taken. Addressing the impact on equalities. From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010? If yes, has a Full Impact Assessment been recommended? If not, why not? Manager s signature: A Gray Date: Dec 17 10

14 Communication and Training Check list for policies Appendix B Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy Is this a new policy with new training requirements or a change to an existing policy? If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below. Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice? Existing Policy Minimal change in knowledge needed other than understanding the content of the policy and the responsibilities it places on staff. Local Security Management Specialists will be subject to ongoing training requirements to help maintain their knowledge base and undertake their responsibilities Individual security specialists to maintain their own competencies. Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Resolutions etc. Please identify the risks if training does not occur. Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training. Is there a staff group that should be prioritised for this training / awareness? Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session; E Learning Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc. Individual security specialists to maintain their own competencies. As identified in the Training Needs Analysis Awareness of policy implementation via e- bulletin. Forms part of Statutory and Mandatory Training. Forms part of the Trust induction programme Forms part of the Staff Handbook Local Security Management Specialists 11

15 Appendix B continued Training Needs Analysis Staff/Professional Group All Groups Type of training Statutory and Mandatory Duration of Training 1 hour 3 years Frequency of Training Copy of completed form to be sent to: Training and Development Department, St. Nicholas Hospital Should any advice be required, please contact: (Option 1) 12

16 Statement Monitoring Tool Appendix C The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework. Security Management Policy - Monitoring Framework Auditable Standard/Key Performance Indicators Executive Director Review of local Security Management Specialists work plan Independent scrutiny of annual report by Board of Directors Review of Security Management arrangements by The Trust Health, Safety and Security Group Frequency/Method/ Person Responsible Annually /Executive Director of Nursing and Chief Operating Officer Annually Executive and Non-Executive Directors Quarterly Head of Safety / Security Where results and any associated action plan will be reported to, implemented and monitored; (this will usually be via the relevant governance group). Health, Safety and Security Group Board of Directors Health, Safety and Security Group The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out. 13