Document Title Security Management Policy
Reference Number CNTW(O)21
Lead Officer Executive Director of Nursing and Chief Operating Officer
Author(s)
(name and designation)
Tony Gray
Head of Safety, Security and Resilience
Ratified By: Business Delivery Group
Ratified Date: Nov 2020
Implementation Date Nov 2020
Date of full implementation Nov 2020
Review date Nov 2023
Version V05
Review and Amendment Log
Version Type of
change Date Description of change
V05 Review Nov 20 Policy Review
This policy supersedes, which should now be destroyed:
NTW(O)21 - 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
Practice Guidance Notes (PGNs) – listed separate to policy U/D = under development
PGN Number Title
SM-PGN 01 Closed Circuit Television Systems
SM–PGN 02 Lone Working
SM–PGN 03 Use of Mobile Comm. Devices
SM–PGN 04 Nuisance and Malicious Calls
SM–PGN 05 Counter Terrorism Response
SM-PGN-06.1 Joint Missing Persons Guidance 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
SM-PGN-09 Identicom Lone Worker Protection System SM-PGN-10 Hospital Lockdown in Emergency situations
SM-PGN-11 Working with Police and Criminal Justice System-replacing ‘Management of Offences’
SM-PGN-15 NEW - Guidance on the aftercare with the use of Taser , CS Incapacitant Spray (CS) and PAVA Incapacitant Spray (PAVA)
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 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust (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.
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) 1999
2.3 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.
3.2 Executive Director of Nursing and Chief Operating Officer
3.2.1 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 Deputy Chief Operating Officer
3.3.1 The Deputy Chief Operating Officer will oversee the corporate function of Security Management and be accountable for the Safety Team.
3.3 Board of Directors
3.3.1 The Board of Directors will create challenge based on the security related reports received at board.
3.4 Head of Safety , Security & Resilience
3.4.1 The Head of Safety, Security & Resilience 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
3.5.1 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)
3.6.1 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.
3.6.2 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
Co-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.
Monitor police investigations and update the member of staff and the Trust on progress.
Ensure details of incidents are recorded on the Trust’s Risk Management System, and ensure they are investigated.
Produce an annual report on security management for assurance and present to the Board of Directors.
3.7 Security Risk Assessments
3.7.1 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.
Security related activity will also be included in the Trust’s Clinical Environmental Risk Assessment for in-patient services.
This will be dependant on escalation of risk.
3.7.2 Action Plans
3.7.2.1 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 can be as result of findings from Incidents, Complaints and Claims.
3.8 Director of Estates & Facilities / Head of Facilities
As part of this policy the Director / 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
3.9.1 The responsibilities of the above are identified in the Terms of Reference (Appendix 1) at the end of this policy.
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 3.
4.2 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
North Cumbria 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
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. As part of this review they will receive the Security Management Annual Report for information.
8 DEFINITIONS OF TERMS USED
LSMS Local Security Management Specialists PGN Practice Guidance Note
SMS Security Management Specialist SPOC Single Point of Contact
Security Risk Assessment – A security risk assessment is a pro-active or re- pro-active assessment 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.
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.
10.2.1 To this end the Trust will provide Statutory and Mandatory Training to support these arrangements.
10.3 Levels of training are identified in the training needs analysis and are included within the Training Guide which can be accessed via this link
http://nww1.ntw.nhs.uk/services/?id=7275&p=2780
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.
11.2 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 CNTW(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).
15.2 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.
17 ASSOCIATED DOCUMENTATION
CNTW(O)01 - Development and Management of Procedural Documents
CNTW(O)05 – Incident Policy - Practice Guidance Notes
CNTW(O)21 - Security Management Policy - Practice Guidance Notes
18 REFERENCES
The Health and Safety at Work etc. Act 1974
CNTW(O)21 Appendix A
Equality Analysis Screening Toolkit Names of Individuals
involved in Review
Date of Initial Screening
Review Date Service Area / Locality
A Gray Nov 2020 Nov 2023 Trustwide
Policy to be analysed Is this policy new or existing?
Security Management Policy – V05 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 2010. 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 No impact Sex No impact Race No impact Age No impact Gender reassignment (including transgender) No impact
Sexual orientation. No impact
Religion or belief No impact
Marriage and Civil Partnership
No impact
Pregnancy and maternity No impact
Carers No impact
Other identified groups No impact
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.
CNTW(O)21
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.
No impact 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 Standard approach to work.
Promote good relations between groups Standard approach to work.
What is the overall impact? 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 No impact.
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: Nov 20
CNTW(O)21
Appendix B Communication and Training Check list for policies
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? 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.
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
Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?
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.
Individual security specialists to maintain their own competencies.
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.
Individual security specialists to maintain their own competencies.
Is there a staff group that should be prioritised for
this training / awareness? Health , Safety & Security Group Members 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
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
Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc.
CNTW(O)21
Appendix B – continued
Training Needs Analysis
Staff/Professional Group Type of training
Duration of Training
Frequency of Training
All Groups Statutory and
Mandatory 1 hour 3 years
CNTW(O)21
Appendix C Monitoring Tool
Statement
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.
CNTW(O)21 – Security Management Policy - Monitoring Framework
Auditable Standard/Key Performance Indicators
Frequency/Method/ Person Responsible
Where results and any associated action plan will be reported to, implemented and monitored; (this will usually be via the relevant governance group). 1. Independent scrutiny of annual report by Board of Directors Annually – Executive and
Non-Executive Directors
Board of Directors
2. Review of Security Management arrangements by The Trust Health, Safety and Security Group
Quarterly
Head of Safety / Security
Health, Safety and Security Group
3. Review of incident reporting activity in relation to security incidents
Monthly as part of incident reporting processes.
CDT – Quality
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.
