Policy: P6. Safekeeping of Patients Property. (local Services) Subsidiary Policy: P6b Patients Personal Possessions Policy Broadmoor Hospital

Policy: P6

Safekeeping of Patients

Property

(local Services)

Subsidiary Policy:

P6b Patients’ Personal Possessions Policy – Broadmoor Hospital

(local Services)

Version: P6/05

Ratified by: Trust Management Team

Date ratified: 16th April 2014

Title of originator/author: Inpatient Service Manager, Ealing Adult SDU Title of responsible Director Director of Nursing and Patient Experience Governance Committee Patient Safety & Safeguarding

Date issued: 17th April 2014

Review date: March 2017

Target audience: All Staff Trustwide

Disclosure Status B Can be disclosed to patients and the public

EIA / Sustainability

Equality & Diversity statement

The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all policies will be required to undergo an Equality Impact Assessment

and will only be approved once this process has been completed

Sustainable Development Statement

The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All policies are therefore required to undergo a

Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be

West London Mental Health NHS Trust_____________________________________ Page 3 of 18

P6: SAFEKEEPING OF PATIENTS PROPERTY (Local Services)

Version Control Sheet

Version Date Title of Author

Status Comment

P6/01 April 1998 Director of Local Services

New policy Titled: Patient Property (Ealing) P6/02 August 2008 Medical Director Policy reviewed and amended Amendment made to Appendix E to reflect Trust Smoke Free Policy

P6/03 16.01.09 Deputy Chief Executive

Policy reviewed and its name changed

Policy Name change from Patient Property (Ealing) to Safekeeping Patients Property (London end)

Review date extended to October 2009 P6/04 May 2011 23rd June 11 Inpatient Service Manager, Ealing Adult SDU Policy revised & issued for consultation

Substantial changes to policy including name change from Safekeeping Patients Property (London end) to Local

Services. Consultation period ends 28th April 2011.

Present to 24th May Policy Review Group for approval – approved as Trust overarching policy – minor amendments required to reflect this. Return to 23rd June PRG for final approval – approved subject to minor amendment.

P6/05 Trustwide consultation ending

05/02/14. Approved at April 2014 TMT.

CONTENTS

PAGE

4.4 Specific Staff for Policy 4.5 All Staff 6 7 7 7 8 9 5 Systems & Recording

5.1 Responsibilities of The Ward Manager And Nursing Staff 5.2 Deposits of Property & Cash on Admission

5.3 Deposits of Valuables & Cash at Patients Bank (Ealing and H&F) 5.4 Deposits of Valuables & Cash Outside Office Hours

5.5 Ward Property Book 5.6 Additional Property

5.7 Personal Articles Retained By Patients 5.8 Additional Property

5.9 Checking Property on Discharge 5.10 Left Behind Property

9

6 Limit Or Disclaim Liability For Loss Of Property 6.1 Patients Incapable Of Looking After Themselves

12

7 Transfer of Property to Third Parties 13

8 Training 14

9 Monitoring 14

10 Fraud Statement 14

11 References 14

12 Supporting Documents 14

13 Glossary Of Terms / Acronyms 15

14 Appendices

Appendix A: Disclaimer of Responsibility Appendix B: Personal Property

Appendix C: Monitoring Plan

15 16 17 18

West London Mental Health NHS Trust_____________________________________ Page 5 of 18

1

FLOWCHART

.

Admission

Two nurses to check the patient’s property together with patient/relative

All property is listed by two nurses in the Ward Property Book

Ward property book to be signed by the patient or relative and both nurses

The property is then recorded on the property checklist which will be checked against the ward property book

Patient/ relative and both nurses sign the Property Checklist

Items Handed in for Safe custody are to be marked with an asterisk (*) on the property checklist

The completed Ward Property Book and Property Checklist are taken together with the Property and cash to the Patients Bank

The Bank Administrator checks all property and cash against the Ward Property Book and Property Checklist and signs the Ward Property Book.

Receipts of Cash are recorded in the Patients Monies Personal Account Receipt Sheet. The receipt sheet is signed by the nurse and attached to the second copy of the Property Checklist

If a patient does not have Capacity or refuses to sign

Relative/ guardian signs disclaimer on behalf of the patient

Nurse in Charge to be present during the recording of the property and be one of the signatories

Patient should sign the Disclaimer acknowledging that any property brought into hospital and not deposited is held at their own risk.

The Disclaimer is to be kept in the patient’s folder.

If a patient is transferred to another ward

Disclaimer should be checked

2

INTRODUCTION

2.1 The hospital is responsible for the health, safety and security of all service users within its care and therefore has a statutory duty to provide a therapeutic, safe living and working environment for service users, staff and to protect the public. To achieve and maintain this, it is essential that restrictions be placed on the amount of possessions that a service user may have whilst in hospital.

2.2 For safety and security reasons the hospital has to achieve a minimum standard of all service users’ rooms all rooms will be searched in accordance with the Search Procedure (OSP) . To facilitate this and minimise fire hazards, a

patient’s room should only contain furniture and personal possessions which can be searched within 30 minutes

3.

PURPOSE

3.1 This policy is a Trust wide policy and therefore applies to all Trust staff. However, because of best practice requirement Broadmoor CSU has particular policy requirements which can be found in subsidiary policy – Patients Personal

Property (P6b).

3.2 To ensure that appropriate systems and procedures are in place for the

management, storage and movement of service users’ personal possessions. 3.3 To ensure patients and their relatives can be assured that valuables brought into

Hospital are accounted for and looked after responsibly by either the patient or staff.

3.4 To provide direction and guidance on the amount and type of personal

possessions that each service user may retain in their room, and stored on or off the ward.

3.5 OBJECTIVE The objective of the policy is to ensure that the hospital’s legal

obligations concerning patients’ property are discharged correctly and that the interests of the staff involved are protected.

4.

DUTIES

DUTIES This policy applies to all those working in the Trust (see point 4.6), in

whatever capacity. A failure to follow the requirements of the policy may result in investigation and management action being taken as considered appropriate. 4.1 Chief Executive

The Chief Executive has the overall responsibility for funds entrusted to the organisation as the accountable officer. This includes instances of fraud, bribery and corruption. The Chief Executive must ensure adequate policies and

West London Mental Health NHS Trust_____________________________________ Page 7 of 18

procedures are in place to protect the organisation and the public funds entrusted to it.

4.2 Accountable Director

The Director of Nursing and Patient Experience is the nominated lead executive director who must ensure that there are robust systems in place to manage

patients property on the wards and that any complaints or concerns are dealt with via PALS/ Complaints department. The Director of Nursing and Patient

Experience has overall responsibility for ensuring the Trust’s compliance with the arrangements of the new Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 and that action is taken in the light of investigations.

4.3 Senior Nurse Managers

Senior Nurse Managers are responsible for ensuring that this policy is

communicated and implemented within their CSU / Directorate as well as co-ordinating and systematically filing monitoring reports. Areas of poor

performance should be raised at the CSU / Directorate SMT meetings. 4.4 Managers

4.4.1 Managers must be vigilant and ensure that procedures to safe keep patients’ property. They should be alert to the possibility that unusual events or

transactions could be symptoms of fraud. Where they have any doubt they must seek advice from the nominated LCFS.

4.4.2 Managers must instil and encourage an anti-fraud culture within their team and ensure that information on procedures is made available to all staff. The LCFS will proactively assist the encouragement of an anti-fraud culture by undertaking work that will raise fraud awareness.

4.4.3 All instances of actual or suspected fraud or bribery, which come to the attention of a manager, must be reported immediately. It is appreciated that some staff will initially raise concerns with their manager, however, in such cases managers must not attempt to investigate the allegation themselves, and they have the clear responsibility to refer the concerns to the LCFS as soon as possible.

4.4.4 Line managers, at all levels, have a responsibility to ensure that an adequate system of internal control exists within their areas of responsibility and that

controls operate effectively. The responsibility for the prevention and detection of fraud therefore primarily rests with managers but requires the co-operation of all staff. As part of that responsibility line managers need to:

inform staff of the Trust code of business conduct and counter fraud and corruption policy as part of their induction process, paying particular attention to the need for accurate completion of personal records and forms;

ensure that all staff for whom they are accountable are made aware of the requirements of the policy;

assess the types of risk involved in the operations for which they are responsible;

ensure that adequate control measures are put in place to minimise the risks. This must include clear roles and responsibilities; supervisory checks; staff rotation, particularly in key posts; separation of duties wherever possible, so that control of a key function is not invested in one individual; and regular reviews, reconciliations and test checks to ensure that control measures continue to operate effectively’;

be aware of the Trust counter fraud policy and the rules and guidance covering the control of specific items of expenditure and receipts; identify financially sensitive posts;

ensure that controls are being complied with; and

contribute to their Director’s assessment of the risks and controls within their business area, which feeds into the Trust and Department of Health

Accounting Officer’s overall statements of accountability and internal control. 4.5 Policy Author

4.5.1 The policy author is responsible for developing or reviewing a policy or procedural document, and complying with the process and requirements of this policy

including formatting and ensuring the appropriate consultation processes as described in the flowchart are followed.

4.5.2 The policy author will receive a ‘policy pack’ from the Policy Administrator and will ensure all the documentation is completed within the given deadlines which

include dates for consultation, approval at relevant governance committee or sub group and ratification at the TMT meeting.

4.5.2.1 Where feasible, Policy authors will feed back to all people who made

comments to advise them if their comments have been included and if not the rationale.

4.5.3 The policy author is also responsible for policy implementation. They will develop implementation plans which will include communicating with all relevant

stakeholders and will ensure all electronic systems and/or manual documentation processes are agreed and available as well as any specific training required to ensure the effective implementation of the policy.(see Flowchart). Line managers will be responsible for ensuring compliance within their teams or service.

4.5.4 The policy author is also responsible for ensuring monitoring plans are appended to the policy to provide evidence of implementation. They must ensure there are robust systems and processes in place to report as specified in the plan.

West London Mental Health NHS Trust_____________________________________ Page 9 of 18

4.6 All Staff

4.6.1 All staff have a duty to protect the assets of the Trust. Assets include information and intellectual property as well as tangible items.

4.6.1.1 Each member staff has a responsibility to ensure that any suspected incidence of fraud, financial irregularity or corruption is identified and reporting

appropriately.

4.6.1.2 Any member of staff who is aware of, but does not report, any suspected fraudulent or corrupt act may be viewed as condoning this and action may be taken under the Trust’s Disciplinary Policy (D4).

4.6.3 It is the responsibility of the Clinical Team to assess the needs, capabilities and risk(s) associated with individual service users. On a day-to-day basis, ward staff are responsible for compliance with this procedure and ensuring the maintenance of accurate records of a service user’s personal possessions, whilst they are held on the Ward. If a risk is involved, the property can be removed or limited.

4.6.4 Those service users who are unable to make informed decisions about their personal possessions will be assisted, as appropriate, in consultation with their Responsible Clinician and Care Coordinator

4.6.5 Each ward must regularly update the inventory of the personal possessions held by each service user on the ward and should create a new list on transfer. PP1. (Appendix 6)

4.6.6 The Clinical Team must consider whether there should be any other restrictions placed on the material the service user may view or listen to in accordance with the Electronic Gaming and Security Procedures and the Sexually Explicit

Materials Policy (S20).

5.0 SYSTEMS AND RECORDING

5.1 Responsibilities of The Ward Manager and Nursing Staff

5.1.1 Ward Manager’s and nursing staff are responsible for advising patients to hand in their property and cash for safe custody. If a patient wishes to keep their

property/cash the Trust’s Disclaimer of Responsibility must be explained to and signed by the patient. The Disclaimer should be kept on the patient’s notes. If a patient refuses to sign the Disclaimer, the nurse must sign the Disclaimer and note on it that the patient refused to sign and has kept their property.

5.2 Deposits of Property & Cash on Admission

1. All property is listed by two nurses in the Ward Property Book. This is done, where possible, in the presence of the patient or relative. It is then signed by the patient or relative and both nurses.

2. When handling patient property and valuables, care should be taken to be sensitive to any cultural or religious beliefs and values that the patient or

Carers may hold.

3. The property is then recorded on a Property Checklist.

4. The Property Checklist is checked against the Ward Property Book and signed by the patient or relative and both nurses.

5. Where a patient is not able to understand the recording or property, the Nurse in Charge must be present during the recording of the property and be one of the signatories.

6. Items handed in for safe custody are marked with an asterisk (*) on the

Property Checklist.

7. If property is handed to relatives, the relative must sign the Property

Checklist as receipt.

8. If Any Patient property is removed from a bedroom in the absence of the patient then this will be entered into the ward property book and stored safely by the nurse in charge. The patient will be informed of this as soon as possible.

5.3 Deposits of valuables & cash at patients bank (ealing and h&f)

1. The completed Ward Property Book and Property checklist is taken, together with the property and cash to the Patients Bank.

2. The Bank Administrator checks all property and cash against the Ward

Property Book and Property checklist and signs the Ward Property Book.

3. Receipts of cash are recorded in the Patients Monies Personal Account

Receipt Sheet. The receipt is signed by the nurse and attached to the

West London Mental Health NHS Trust_____________________________________ Page 11 of 18

5.4 Deposits of valuables & cash outside office hours.

1. The Property Card is completed as per point 8.2

2. All property/cash and the top copy (white) of the Ward Property Book is placed in the Patients Property Envelope and sealed. Any

breakable/valuable items must be securely wrapped.

3. Both nursing staff must sign across the seal of the envelope. 4. The envelope is marked with the patient’s name and ward.

5. 5. The envelope is taken to the designated site night safe where the following details are entered in the night safe register:-

Date of deposit Time of deposit Ward/department

Name of depositing officer

Description of deposit (i.e., sealed envelope, patients effects) 5.4.1 The envelopes are collected by the Bank Administrator (Ealing and H&F) from the

night safe on a daily basis (excluding weekends). They are retained in the Patients Bank until nursing staff bring the Ward Property Book to the bank where the above procedure is carried out.

5.5 Ward property book

Top Copy (white) is retained by the Patients Bank

Second Copy (pink) with the receipt attached is returned to the nurse and is

either filed in the patient’s notes or given to the patient

Third Copy (blue) is retained in the Ward Property Book which is returned to

the nurse.

5.6 Additional property

5.6.1 The Property Checklist must be updated by nursing staff when informed of additional property being acquired during the patient’s stay.

5.7. Personal articles retained by patients

5.7.1 The Trust has a duty to prevent thefts and to keep furniture and equipment in good repair. Any damage or loss to patients property resulting from a failure to do so could make the Trust liable for such damage or loss.

5.8. Checking property on discharge or death

5.8.1 Checking a patients property on discharge is as important as recording it on admission. Nursing staff must go through the patient’s property on the Property Checklist with the patient prior to discharge.

5.8.2 In the event of a patient death property should be checked prior to handing over property to nearest relatives. All property MUST be transferred to family members in a designated property box.

5.9. Left-behind property and lost property

5.9.1 If property is found for a known patient once they have been discharged then the following process should take place:

5.9.2 Where the identity of the patient is known a letter should be sent to the patient (by the Ward Manager/Clinical Team Leader) saying they have left property behind and it can be collected from the ward/department they were on.

5.9.3 Property should be kept securely on the ward for one month and then passed on to the patient affairs department.

6

ACTION REQUIRED TO LIMIT OR DISCLAIM LIABILITY FOR

LOSS OF PROPERTY

6.1 The items will be clearly recorded and described in terms of quantity and quality, and for electrical goods the serial number noted.

The quality of the items will be recorded as follows:

When completing the record, staff should take care to describe items accurately and not to use terms that could be ambiguous. For example, the terms ‘gold’, ‘silver’, or ‘diamond’ etc should be avoided, and descriptive terms such as ‘yellow metal’, ‘grey metal’ or ‘white stone’ etc should be used instead.

6.2 The DOH advises NHS Trusts to disclaim liability for the loss of money, valuable articles or personal effects except when they are taken into safe custody. It is recommended that a Disclaimer of Responsibility should accompany the form of admission. See Appendix A.

6.2.1 If possible, patients should sign the Disclaimer acknowledging that any property brought into the hospital and not deposited is held at their own risk. If the Trust

N = New WT = Wear and Tear BR = Broken M = Marked

S = Soiled SC = Scratched T = Torn

West London Mental Health NHS Trust_____________________________________ Page 13 of 18

omits to obtain these acknowledgements and property remains under the control of patients, the Trust could be liable in an action for loss due to negligence. The Trust is not, however, responsible for damage to patient’s property (particularly if this is due to natural causes which could not reasonably have been foreseen, such as a storm, flood etc.), unless it was attributable to the negligence of staff. 6.2.2 A warning notice must be publicly displayed in all wards, clinics, health centres

and Mental Health Resource Centres and brought to the attention of all patients and relatives. See Appendix B.

6.2.3 Out-patients and day patients are not normally required to hand over money or valuables, but if such patients have to undress for treatment or examination and are unable to take their clothing with them, the Trust may be liable for loss by theft. The provision of accommodation for changing is a necessary part of treatment and if facilities are inadequate, the Trust may be held liable if loss or damage occurs.

6.3 Patients Who Lack Mental Capacity

6.3.1 When patients admitted to hospital are mentally ill or for any other reason incapable of looking after themselves, there is a duty on the Trust to have the contents of their clothing examined and placed in safe custody. The examination and check should take place in the presence of two members of staff

6.3.2 If the patient is confused on admission and unable to sign the trust disclaimer, every effort should be made to obtain a signature at the first appropriate opportunity.

6.3.3 Where the patient cannot sign the disclaimer section on admission, because the patient is confused and the patient is accompanied by a relative or guardian, this person should be asked to sign on behalf of the patient, their name should be clearly written next to the signature.

6.3.4 Where the disclaimer cannot be signed by the patient on admission and the patient is unaccompanied, the patient should be asked to sign as soon as

possible thereafter, and a reason for signing on a later date recorded on the form. 6.3.5 When a patient is transferred to a different ward, the disclaimer should be

checked and completed where this is not already done.

7

TRANSFER OF PROPERTY TO THIRD PARTIES

Normally, property should not be handed over to third parties without the consent of patients, but articles of small value and clothing may be handed to friends or relatives and receipts obtained. Money and valuables should, however, be retained by the Trust until the patient has recovered sufficiently to give

instructions as to their disposal. If this is not done, patients may have the right to sue for compensation and breach of responsibility.

8

TRAINING

There is no specific training for this policy, however this should be part of the secondary induction training. Awareness sessions as and when required.

9

MONITORING

The policy will be reviewed every three years by the Audit Committee and changes recommended to the Board. Internal audit will check that the policy is being

adhered to as part of their review of internal controls and will report their findings to management and to the Audit Committee.

10

FRAUD STATEMENT

10.1 West London Mental Health Trust adopts a zero tolerance attitude to fraud and corruption, money laundering or any similar illegal act within the NHS. The aim is to eliminate all fraud within the NHS as far as possible. The Trust already has procedures in place that reduce the likelihood of fraud occurring. These include standing orders, standing financial instructions, documented procedures, a

system of internal control and a system of risk assessment. In addition, the Trust tries to ensure that a risk (and fraud) awareness culture exists in the Trust.

10.2 The WLMHT Counter Fraud Policy and Reporting Procedure (F2) policy identifies the expectation of the Trust of those working in the public sector, and how it will address and investigate any suspected fraud, corruption, money laundering and financial irregularity.

11

REFERENCES

None

12

SUPPORTING DOCUMENTS

F2 Counter Fraud Policy and reporting procedures P6b Search Procedure

W1 Whistle blowing policy B2 Business Conduct

S20 Patients Access to Sexually explicit and Sexually Violent Material D4 Disciplinary Policy

West London Mental Health NHS Trust_____________________________________ Page 15 of 18

13

GLOSSARY OF TERMS / ACRONYMS

NHS National Health Service CSU Clinical Service Unit

LCFS Local Counter Fraud Specialist TMT Trust Management Team SMT Senior Management Team H&F Hammersmith and Fulham DOH Department of Health

14 APPENDICES

Appendix A: Disclaimer of Responsibility Appendix B: Personal Property

APPENDIX A

DISCLAIMER OF RESPONSIBILITY

You are advised to restrict to a minimum the amount of property including cash brought into the hospital and to hand to the nursing staff, as soon as possible, any articles you wish to be kept in safe custody for which a receipt will be given to you. You are

responsible for property including cash not handed in for safe custody. West London Healthcare NHS Trust accepts no responsibility for the loss of or damage to personal property of any kind in whatever way the loss or damage may occur unless deposited for safe custody.

The above statement has been explained to me and I accept and understand its contents. Signature of Patient...Date... Signature of Nurse...Date... Signature of Nurse...Date...

West London Mental Health NHS Trust_____________________________________ Page 17 of 18

APPENDIX B

WARNING

PERSONAL PROPERTY

‘Notice is hereby given that the West London Mental Health NHS Trust accepts no responsibility for the loss of or damage to personal property of any kind, including money, in whatever way the loss or damage may occur unless an official receipt is obtained from the Ward Manager/Nurse In Charge for property which has been handed in for safe custody’.

APPENDIX C

MONITORING PLAN

POLICY / PROCEDURE:

P6 Safekeeping of patients Property

MONITORING TEMPLATE Minimum Requirement to be Monitored Where Described in the Policy WHO

(which staff / team / dept) HOW MONITORED (Audit / process / report / scorecard) - list details HOW MANY RECORDS (No of records / % records) FREQUENCY (monthly / quarterly / annual) REVIEW GROUP (which meeting / committee) OUTCOME OF REVIEW / ACTION TAKEN (Action plan / escalate to higher meeting)

1) Whether all the forms are been completed properly for all the patients on admission.

Section 5.2, 5.3, 5.5, 5.8

Ward Managers and Clinical Team

Leaders Audit 100% Monthly

SMT & Clinical Audit SMT & TMT