Putting Barnsley People First

Barnsley Clinical Commissioning Group Security Policy and Procedure

Version:	Approved v1.0
Approved By:	Governing Body
Date Approved:	August 2015
Name of originator / author:	Richard Walker/Ruth Nutbrown
Name of responsible committee/ individual:	Health & Safety Group
Name of executive lead:	Richard Walker
Date issued:
Review Date:	2 years from date of approval
Target Audience:	All CCG Staff

Security Policy and Procedure

DOCUMENT CONTROL

Version No	Type of Change	Date	Description of change
v0.1	Document developed	April 2015	New document
V0.2	Drafting changes	July 2015	Minor changes following review of the original draft by Head of Assurance and Management Team
V0.3	Drafting changes	August 2015	Further minor drafting amendments
V1.0	Approved version	August 2015	Version approved by Governing Body on 13th August 2015
V1.1	Minor amendments	November 2016	Change of named Executive lead Vicky Peverelle to Richard Walker Change of named Security Management Director from Chief of Corporate Affairs to Head of Governance and Assurance Reference to Yorkshire and Humber Commissioning Support removed and replaced by South Yorkshire and Bassetlaw Clinical Commissioning groups Reviewed and updated the Lone working Risk Assessment (Appendix 4) Reviewed and updated the Equality Impact Assessment (Appendix 5)

BARNSLEY CLINICAL COMMISSIONING GROUP Security Policy and Procedure
Contents 1 Introduction 4 2 Purpose 4 3 The risks of not having this policy in place 5 4 Principles 5 5 Roles and responsibilities 5 6 Procedure 9 7 Monitoring the compliance and effectiveness of this Policy 15 8 References 15 9 Review of the Policy 15 Appendix 1 Definitions 16 Appendix 2 Reporting of crime/security incidents 18 Appendix 3 Lone Worker Procedure 20 Appendix 4 Lone Worker Risk Assessment 28 Appendix 5 Equality Impact Assessment 2013 30

1.	Introduction
1.1	NHS Barnsley Clinical Commissioning Group (CCG) is committed to a safe and secure environment that protects staff, patients and visitors, and their property and the physical assets of the CCG, via Health and Safety legislation, by Department of Health Policy and by common law duty of care. This policy aims to deal proactively with the CCG’s security arrangements.
1.1.1	The CCG acknowledges its responsibility for the safety of people within the organisation and wider, and the requirement to have a written statement of general policy under the statutory requirements of: ● the Health and Safety at Work Act 1974 ● NHS Protect guidance “Standards for Commissioners”
1.1.2	The Security policy has been developed in accordance with the CCG’s Policy on the Development and Management of Policies and Procedures
1.1.3	This policy needs to be read in conjunction with the: Corporate Manual Fraud, Corruption and Bribery Policy Fire Safety Policy Health and Safety Policy
2.	Purpose
2.1	The CCG recognises its responsibilities to ensure that reasonable precautions are taken to provide a safe and secure working environment and that steps are taken to prevent issues in relation to security management, in compliance with relevant statutes and codes of practice (as identified above).
2.1.1	In pursuance of this aim, the CCG will: Protect the safety, security and welfare of staff, patients and the general public whilst on CCG premises Provide systems and safeguards against crime, loss, damage or theft of property and equipment Minimise disruption or loss of service to patients/clients Ensure Risk Assessment and security audits are implemented to comply with statute.
2.1.2	The CCG recognises that this Policy Statement is implemented in pursuance of these aims.
3.	The Risks of not having this Policy in place
3.1	Not having this policy in place exposes the CCG to increased risk of failure to meet its legal responsibility to provide a safe and secure environment that protects staff, patients and visitors, and their property and the physical assets of the CCG.
4.	Principles
4.1	It is the CCG’s intention to take all reasonable practicable steps to reduce the associated risks from security issues.
4.1.1	The CCG will also ensure, so far as is reasonably practical, that all employees who are required to work alone for significant periods of time are protected from risks to their health and safety.
5.	Roles and Responsibilities
5.1	Security is a management responsibility and the provision of a security service in no way relieves management at any level of its obligations to fulfill the stated purpose of security in the CCG. Managers are required not only to exercise preventative aspects but also to take appropriate action where necessary in respect of those who offend against the law, commit misconduct or other breach of security in contravention of the policies of the CCG.
5.2	Overall accountability for ensuring that there are systems and processes to effectively manage security lies with the Chief Officer who takes the risks to the CCG from breaches of security seriously and seeks to reduce the numbers of incidents occurring as a direct result. Responsibility is also delegated to the following individuals:
5.2.1	The Head of Governance and Assurance functions as the Security Management Director and has lead responsibility for the development and strategic review of security within Barnsley CCG, in line with the Secretary of State’s Directions of November 2003. The Security Management Director is responsible for: The formulation, implementation and maintenance of an effective Security Policy, (following NHS Protect guidance) in consultation with staff representatives, and ensuring that Managers co-ordinate and implement the Policy in their respective areas Reviewing and amending this policy to ensure compliance with any current guidance Instituting regular campaigns to highlight the importance of security and the responsibilities of all CCG staff Leading Security Management within the CCG and identifying security initiatives for improving the security across the CCG Advising the CCG of any requirements, statutory or other, by the preparation of procedures for dealing with crime prevention, supply of security systems and maintenance Monitoring the performance of the CCG with regard to the implementation of this policy.
5.2.2	The nominated Local Security Management Specialist (LSMS) for the CCG is the Head of Specialist Advice, Health and Safety (South Yorkshire & Bassetlaw Clinical Commissioning Groups. (SY&BCCG)). The overall objective of the LSMS will be to work on behalf of Barnsley CCG to deliver an environment that is safe and secure. This objective will be achieved by working in close partnership with stakeholders within Barnsley CCG, NHS Protect and external organisations such as the police, professional representative bodies and trade unions. The LSMS will aim to provide comprehensive, inclusive and professional security management services for Barnsley CCG and work towards the creation of a pro-security culture within the NHS. The LSMS will: Report to Barnsley CCG Security Management Director (SMD) on security management work locally Lead on the day to day work within Barnsley CCG to tackle violence against staff and professionals in accordance with national guidance Ensure that lessons are learned from security incidents, and that these incidents are assessed and the impact on the CCG reported to appropriate authorities in accordance with guidelines issued by the NHS SMS Investigate security incidents/breaches in a fair, objective and professional manner so that the appropriate sanctions (and allow consideration of preventative action to be taken) Ensure that the security management policy addresses all the organisations identified risks and contains all the required elements from NHS Protect guidance Ensure that the security management policy is reviewed or evaluated to establish its effectiveness Ensure that any corrective or preventative actions identified as a result of the policy review or evaluation are implemented, to ensure that the security management policy continues to address the CCG’s identified risks.
5.2.3	Other Chiefs of Service, on behalf of the Chief Officer are responsible for ensuring that the CCG’s Security Policy is implemented within the organisation. This will include responsibility for: Planning any capital investment required to address matters arising from risk assessments Security risk assessment within their areas and for ensuring that staff for whom they are responsible are aware of these risks Preventative measures and appropriate action in respect of persons who are suspected of committing a criminal offence, misconduct or other breach of security in contravention of the policies of the CCG Ensuring staff awareness of and how to access this policy and other relevant documents and their responsibilities and also ensure that staff (including temporary staff) receive training appropriate to the risks involved Ensuring that security arrangements within their area are being observed and that deficiencies are reported Ensuring that any particular security problems known to them are reported accordingly Actively reviewing the security arrangements within their area by carrying out routine audits themselves with the co-operation of staff organisations, in line with CCG risk assessment procedures Ensuring that every member of staff obtains a security ID Badge and that the badge is worn and visible at all times whilst the staff member is on CCG premises or on CCG business An ongoing commitment to staff training, carrying out risk assessments, identifying areas at greatest risk and eliminating or controlling these risks.
5.2.4	Line Managers are responsible for: Ensuring compliance with CCG Security Policy requirements in the areas for which they are responsible The completion of any risk assessments required in relation to security of staff or premises Ensuring that any security problems known to them are reported accordingly
5.2.5	Responsibilities of Staff (including all employees, whether full / part time, agency, bank or volunteers) are: To co-operate with management to achieve the aims and objectives of the Security Policy. Great emphasis is placed on the importance of co-operation of all staff in observing security and combating crime. The protection and safe keeping of their private property. Any loss of private property must be reported without delay. If private property has been stolen, then it is the owner’s responsibility, not the CCG’s responsibility to contact the Police. To familiarise themselves with any special security requirements relating to their place of work or work practices the action to take in the event of a security incident. To safeguard themselves, colleagues, visitors, patients/clients etc., so far as is reasonably practicable, and ensure that neither equipment nor property are put in jeopardy by their actions or omissions, either by instruction, example or behaviour. To follow prescribed working methods and security procedures at all times. To co-operate with managers to achieve the aims of the Security Policy. To comply with all training requirements concerning security issues. To ensure that the CCG ID is worn and visible whenever on CCG premises or on CCG business. To notify their line manager of any potential security problems and report all incidents involving criminal activity to the appropriate manager. To report any crime/breach of security. This procedure is documented as Appendix 2. All staff are reminded that it is an offence to remove property belonging to the CCG without written authority. Failure to seek authority from their line manager could result in disciplinary action or criminal proceedings being taken. NHS Barnsley CCG will not accept liability for the loss of, or damage to private property including motor vehicles or other modes of transport. Motor vehicles are brought onto the sites entirely at the owner’s risk. NHS Barnsley CCG will take reasonable steps to safeguard vehicles on their property.
6.	Procedure
6.1	Employment
6.1.1	All persons applying for a post within the CCG must have completed the section on the application form entitled Rehabilitation of Offenders Act 1974. This section states that ‘because of the nature of the work for which you are applying, this post is exempt from provisions of Section 4(2) of the Rehabilitation of Offenders Act, 1974 (Exemption) Order, 1975.’ Applicants are therefore, not entitled to withhold information about convictions which for purposes are ‘spent’ under the provisions of the Act, and in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action by the CCG.
6.1.2	This application form also requests details of any convictions, adult cautions or bind-overs, and requires the applicant to sign the statement confirming that the information given is correct. For more information refer to the Recruitment & Selection Policy.
6.1.3	In accordance with the provisions of the Children’s Act 1989, the CCG must ensure that, staff who occupy certain positions that brings them regularly in contact with children have Disclosure & Barring Service check which will be requested as appropriate following appointment of the staff member by the Human Resources Department.
6.2	Personal Security
6.2.1	Specific procedures for local needs such as domiciliary visits (e.g. lone workers), staff in other premises, reception staff, agile workers etc. are to be developed and implemented by individual departments. All staff must follow existing Health & Safety policies and guidelines.
6.2.2	The requirement for security personnel (e.g. static or mobile guards) should be assessed by local managers and managed within each Department. The Local Security Management Specialist (LSMS) can advise and help manage arrangements if so required.
6.3	Staff Identification
6.3.1	Every employee, including bank staff, will be issued with an identification badge on commencement of employment which must be worn at all times whilst on CCG premises or on official business.
6.3.2	Each member of staff is personally responsible for their badge, and to ensure that the badge is up to date and that there are no radical changes in physical appearance, title or department. All staff should wear an official CCG identification badge and it is the responsibility of each departmental manager to ensure that this is implemented. The identity badge will state the employee name and job title and must be clearly visible to other staff, and visitors.
6.3.3	Identification badges must be returned to the Human Resources Department when a member of staff leaves the employment of the CCG. It is the responsibility of the line manager to recover the identity badge from the member of staff concerned and return it to the HR Department.
6.3.4	For the Management of Contractors please refer to the Control of Contractors Procedure.
6.4	Cash Movement/Handling
6.4.1	Only the Finance Team should hold cash, which will be managed in accordance with the Petty Cash Procedure.
6.5	Funding
6.5.1	Each Department must take into account security issues including cost implications when: Developing schemes for minor improvements Developing schemes for new premises, major upgrading etc Introducing new services or changes to existing services, which may have implications for staff security.
6.6	Key Holding
6.6.1	The responsibility for the arrangements for daily opening / closing of premises rests with the Security Management Director (SMD). This includes the maintenance of a key register which identifies the location of all keys. The register should detail the individuals in receipt of keys and signatures should be obtained.
6.7	Access and Egress
6.7.1	Access to NHS Barnsley CCG premises will be restricted. The responsibility for the arrangements for daily opening / closing of premises and individual departments rests with the SMD.
6.7.2	Where appropriate, access will be controlled by the use of digital locks, electronic alarm systems and access to keys.
6.7.3	All windows at ground level, where appropriate, will be fitted with security devices or restrictors limiting the extent to which they can be opened.
6.7.4	The Security Management Director will put in place measures to ensure that locking systems and alarm codes are reviewed on a regular basis.
6.8	Security of Goods
6.8.1	Goods received into the organisation must be checked against delivery notes prior to signing for acceptance. The organisation will provide secure accommodation for goods awaiting distribution.
6.8.2	Some CCG goods are received by South and West Yorkshire Partnership Foundation Trust (SWYPFT). These goods will remain the responsibility of SWYPFT until signed for by a CCG staff member.
6.8.3	All CCG departments receiving goods must ensure there are procedures in place to monitor the receipt of goods and safe/ secure systems are in place to protect goods from theft or inappropriate use.
6.9	Security of Personal Belongings
6.9.1	All staff should ensure that personal belongings are stored in a secure location e.g. locked in cupboards, lockers or desk drawers. NHS Barnsley CCG cannot be held responsible for theft of personal items.
6.10	Fraud
6.10.1	The responsibilities for fraud prevention are described in the CCG Fraud, Corruption, and Bribery Policy. The Local Security Management Specialist will liaise regularly with the Local Counter Fraud Specialist to ensure a direct and close relationship is maintained.
6.11	Fire
6.11.1	The overlapping interests of security and fire safety policies are fully recognised and there is full co-operation between fire and security staff.
6.12	Information Security
6.12.1	Information security risk is inherent in all administrative and business activities and everyone working for or on behalf of NHS Barnsley CCG continuously manages information security risk. The aim of information security risk management is not to eliminate risk, but rather to provide the structural means to identify, prioritise and manage the risks involved in all our organisational activities. It requires a balance between the cost of managing and treating information security risks with the anticipated benefits that will be derived.
6.12.2	All information is held in accordance with the CCG’s Information Governance Strategy Framework, Policy and associated procedures. Further information can be found in the organisation’s Information Security Management Statement and Assurance Plan.
6.13	Violence and Aggression
6.13.1	Any member of the public, patients or otherwise who are violent towards CCG staff may have sanctions taken against them, be refused treatment, or taken to court by the CCG in line with NHS Protect Guidance.
6.14	Emergency Preparedness, Resilience & Response
6.14.1	A significant incident or emergency can be described as any event that cannot be managed within routine service arrangements. Each requires the implementation of special procedures and may involve one or more of the emergency services, the wider NHS or a local authority. Please refer to the Emergency Preparedness, Resilience & Response Policy for further details.
6.15	Risk Assessment
6.15.1	The Management (Health, Safety and Welfare) Regulations 1999 (Regulation 3) require that suitable and sufficient risk assessments be undertaken, so that the significance of a hazard can be identified, assessed and controlled. Guidance on Assessing risks to safety and health can be found in the CCG’s guidance document – Risk Assessment Matrix. Please refer to the Integrated Risk Management Framework, Strategy, Policy and Procedure for further information.
6.15.2	Risks associated with security should be reported to the Local Security Management Specialist (LSMS).
6.15.3	Risk Assessments should be completed for all security hazards including physical (buildings, equipment etc.) and people. These risk assessments are the responsibility of the department involved, with support from the Local Security Management Specialist (LSMS) where required.
6.15.4	Risks relating to security are identified on an ongoing basis through incident reports, complaints and claims procedures, and the risk assessment procedure.
6.15.5	It is important that all staff within the CCG are aware of the security risks involved within their work. They must also be aware of formal risk assessments that apply to them, the actions identified to control the risks and the measures to be taken by them personally to reduce the risks to themselves and others.
6.15.6	When working arrangements are agreed with an individual which result in that person working alone for regular / significant periods, then the manager will be responsible for ensuring that a risk assessment is undertaken and that a related safe system of work is put in place. This will take into account the capability of the individual. The employee will be required to conform to these arrangements, to safeguard both themselves and NHS Barnsley CCG.
6.15.7	Working alone is not illegal, but it can bring additional risks to a work activity. The CCG has developed policies and procedures to control the risks and protect employees, and employees should know and follow them. Apart from the employee being capable of undertaking the work / detail the three most important aspects to be certain of are that: The lone worker has full knowledge of the hazards and risks to which they are exposed. The lone worker knows what to do if something goes wrong. Someone else knows the whereabouts of the lone worker and what he/she is doing

7.	Monitoring the Compliance and Effectiveness of this Policy
7.1	The Health and Safety Group will be responsible for monitoring compliance with, and the effectiveness of, this policy. In discharging this responsibility the Health and Safety Group will take into account: Any security incident reported via the CCG’s incident reporting system The results of the annual security audit Self-assessments against NHS Protect’s security standards.
8.	References
8.1	The following legislation and guidance has been taken into consideration in the development of this procedural document:
8.1.1	The Private Security Industry Act 2001 The Regulation of Investigatory Powers Act 2000 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995. Data Protection Act 1998 The Protection from Harassment Act 1997 Control of Substances Hazardous to Health 2004 Approved Codes of Practice The Health and Safety at Work Act 1974 Human Rights Act 1998 Criminal Procedure and Investigation Act 1996 Police and Criminal Evidence Act 1984 Criminal Justice and Public Order Act 1994 CCTV Code of Practice 2000 Standards for Commissioners 2015-16 NHS Protect.
9.	Review of the Policy
9.1	The policy will be approved by the Governing Body and reviewed at least every 2 years. The Health and Safety Group will monitor the policy on an ongoing basis. The procedural document will be reviewed every two years, and in accordance with the following on an as and when required basis:
9.1.1	Legislatives changes Good practice guidelines Case Law Significant incidents reported New vulnerabilities identified Changes to organisational infrastructure Changes in practice

Appendix 1

Definitions
1.	NHS Protect The NHS Counter Fraud Service was established in 1998 as a specialist organisation with the commitment to protect the NHS by ensuring that resources made available to patient care and services are not lost to fraud and corruption. The much larger CFSMS was officially inaugurated as a Special Health Authority on 1st April 2003. Since 1st April 2006 it has been a division of the NHS Business Services Authority, and is strategically placed with its operational and policy roles to effectively counter fraud and, with a wide remit to manage healthcare security arrangements within the NHS. The organisation changed its name to NHS Protect in 2011 and continues to lead on work to identify and tackle crime across the health service.
2.	Local Security Management Specialist (LSMS) The Local Security Management Specialist (LSMS) is highly trained by NHS Protect and will be involved in performing a wide range of security-related tasks: Creating a ‘pro-security’ culture amongst staff, professionals and the public Deterring those who may be minded to breach security Preventing security incidents or breaches from occurring Detecting security incidents and reporting them to NHS Protect Investigating security incidents in a fair, objective and professional manner Applying a wide range of sanctions against those responsible for security incidents, involving a combination of procedural, disciplinary, civil and criminal action as appropriate Seeking redress through the criminal and civil justice systems against those whose actions lead to loss of NHS resources To deter Criminal activities where possible by putting in place essential security control systems and other counter measures To deny the criminal opportunity, not only through physical barriers, but by putting in place effective systems of loss prevention and property control To detect the criminal act. The earlier the criminal act is detected and reported the greater the chances of preventing the offenders getting away. Raised awareness of security at all levels will both detect and reduce the risk of crime To respond effectively to security issues and problems with workable counter measures To review the strategy after every incident, also after counter measures have been put in place to evaluate their effectiveness To liaise with the local police and the local authority to achieve partnership working towards a safe and secure environment The Local Security Management Specialist will work closely with the Local Counter Fraud Services Officer to prevent and detect crime and fraudulent activities.
3.	Property Can be defined as the physical buildings in which NHS staff and professionals work, where patients are treated and from where the business of the NHS is delivered. Ref: A Professional Approach to Managing Security in the NHS, NHS Counter Fraud and Security Management Service (2003) http://www.nhsbsa.nhs.uk/Documents/sms_strategy.pdf
4.	Assets Assets, irrespective of their value can be defined as the materials and equipment used to deliver NHS healthcare. In respect of staff, professionals and patient sit can also mean the personal possessions they retain whilst working in, using or providing services to the NHS. A Professional Approach to Managing Security in the NHS, NHS Counter Fraud and Security Management Service (2003) http://www.nhsbsa.nhs.uk/Documents/sms_strategy.pdf
5.	Premises Premises are land and buildings together considered as a property. This usage arose from property owners finding the word in their title deeds, where it originally correctly meant "the aforementioned; what this document is about", from Latin prae-missus = "placed before". Wikipedia (2015) http://en.wikipedia.org/wiki/Premises

Appendix 2

Reporting of Crime / Security Incidents

All staff have a responsibility to report any crime / breach of security. This reporting falls into the following categories:

NHS Barnsley CCG Premises - Hillder House

Where a crime/security incident of a serious nature occurs and is happening there and then, dial 999 and report to police, and then the Security Management Director or their Deputy should be informed.

Where a security/criminal incident is discovered, the information should be passed to the Security Management Director or their Deputy and the Local Security Management Specialist as soon as practicable.

Completion of an Incident Reporting Form (as per Incident Policy) and a copy should be forwarded to the Local Security Management Specialist.

External Locations

Where a crime / security incident of a serious nature occurs and is happening there and then, you should call the police immediately by telephoning 999.

Where a security incident is discovered, the information should be passed to the Security Management Director or their Deputy as soon as practicable.

Completion of an Incident Report Form (as per Incident Policy) and a copy should be forwarded to the Local Security Management Specialist.

Out of Hours

Where a crime / security incident of a serious nature occurs and is happening there and then, you should call the police immediately by telephoning 999.

Following this the incident should be reported to the Security Management Director or their Deputy as soon as possible.

Suspicious (suspect) packages

A suspect package is a package believed to contain a potentially harmful device or substance.

Any suspect package (postal item, e.g. letter / package) when received must immediately be placed in isolation (and not moved again) and away from water, chemicals, heated surfaces, naked flames and gaseous substances. It is more likely to be an incendiary device than a bomb; i.e. it is designed to start a fire.

Do not shake it, squeeze, or open the letter or package.

Turn off all air conditioners, fans, photocopiers, printers, computers and heaters within the room where the letter / package is located. Close all windows and evacuate the room, lock all doors and leave the key in the lock. Place a clearly visible warning on the door.

Any suspicious packages (other items e.g. bags, boxes that have appeared) should NOT be moved and its position should be reported to the Security Management Director or their Deputy or a member of the Senior Management Team. Undertake initial investigation (without touching or moving the package) identifying:

The listed owner of the package

Visible wires or electrical components showing from the package, especially where the wrapping has been damaged

Any greasy marks on the envelope or package

If an unknown powder or liquid substance is leaking from the package

Distinctive smells from the package e.g. almonds / marzipan or machine oil

If the package when delivered was heavy for its size or has an uneven distribution of weight or has excessive wrapping

If the package was delivered by hand from an unknown source or posted from an unusual place

If in doubt, dial 999 and report to police and evacuate the building without sounding the fire alarm and closing doors and windows behind you.

Do not use mobile telephones near suspect packages.

If you feel you may have been contaminated, go to an isolated room and avoid other people if you can. It is vitally important that you segregate yourself and others who may have come into contact with the suspicious package. It is unlikely that you have been contaminated and you will get medical treatment if required. Signs that people may have been exposed to a chemical incident are streaming eyes, coughs and irritated skin. Do not rub your eyes; touch your face or other people. Thoroughly wash your hands in soap and water as soon as possible.

Where convenient, fire assembly points can be utilised for the purpose of evacuation, but only if they are located at a distance of at least 400 metres from the suspected bomb site. Safe assembly points are best situated behind a solid building at a distance away from the blast site.

Bomb threats

A bomb threat is a threat to detonate an explosive or incendiary device to cause property damage or injuries, whether or not such a device actually exists. Bomb threats are usually made verbally over the phone.

Notification of a bomb threat can be made at any time and can be made and delivered by several means, usually anonymous, but all must be considered seriously.

Any member of staff receiving a telephone threat regarding a suspect package or explosive device should obtain as must detail as possible from the caller. The police need to be informed immediately - dial 999 and report to police and evacuate the building without sounding the fire alarm and closing doors and windows behind you. Report the situation to the Security Management Director or their Deputy or a member of the Senior Management Team who will decide whether an emergency should be declared in line with the Emergency Preparedness, Resilience & Response Policy.

Appendix 3

Putting Barnsley People First

Barnsley Clinical Commissioning Group Lone Worker Procedure

Version:	1.0
Approved By:	Health & Safety Group
Date Approved:	October 2014
Name of originator / author:	Ian Plummer, Ruth Nutbrown & Richard Walker
Name of responsible committee/ individual:	Health & Safety Group
Name of executive lead:	Vicky Peverelle
Date issued:	October 2014
Review Date:	2 years from approval
Target Audience:	All Barnsley CCG staff

LONE WORKER PROCEDURE

Amendment Log

Version No	Type of Change	Date	Description of change
V0.1	First Draft	September 2014
V1.0	Final	October 2014	Finalised following H&S Group approval on 6.10.2014

CONTENTS

PAGE
1.	Introduction	22
2.	Purpose	22
3.	The Risks of not having this procedure in place	22
4.	Definitions	22
5.	Principles	22-23
6.	Roles and Responsibilities	23
7.	Development, Approval and Implementation	23
8.	Procedure	23-26
9.	Monitoring the Compliance and Effectiveness of this Procedure	26
10.	References	26
11.	Review of this Procedure	26

BARNSLEY CLINICAL COMMISSIONING GROUP LONE WORKER PROCEDURE
1.	Introduction
1.1	This procedure sets out the steps the CCG will take to keep lone workers healthy and safe. The procedure has been developed in accordance with the CCG’s Policy on the Development and Management of Policies and Procedures.
2.	Purpose
2.1	Working alone is not in itself against the law and it will often be safe to do so. However, the law requires employers to consider carefully, and then deal with, any health and safety risks for people working alone.
3.	The risks of not having this procedure in place
3.1	In the absence of this procedure there is an increased risk that the CCG will not effectively discharge it’s responsibility to address the health and safety risks for people working alone.
4.	Definitions
4.1 4.2	The Health and Safety Executive (HSE) defines lone workers as: “Those who work by themselves without close or direct supervision” Further HSE definition examples include lone workers who work by themselves without close or direct supervision such as: only one employee works on the premises employees work separately from others employees work outside normal hours It is recognised that any employee may spend a limited amount of their working time ‘alone’.
5.	Principles
5.1	Lone workers should not be put at more risk than other employees. Establishing a healthy and safe working environment for lone workers can be different from organising the health and safety of other employees. Employers should take account of normal work and foreseeable emergencies, eg fire, equipment failure, illness and accidents. Employers should identify situations where people work alone and consider the following: Does the workplace present a specific risk to the lone worker? Is there a safe way in and out for one person, eg for a lone person working out of hours where the workplace could be locked up? Is there a risk of violence and/or aggression? Are there any reasons why the individual might be more vulnerable than others and be particularly at risk if they work alone (for example if they are young, pregnant, disabled or a trainee)? If the lone worker’s first language is not English, are suitable arrangements in place to ensure clear communications, especially in an emergency?
6.	Roles and Responsibilities
6.1 6.2 6.3	The CCG is responsible for the health, safety and welfare at work of all its workers including any contractors or self-employed people doing work for the CCG. These responsibilities cannot be transferred to any other person, including those people who work alone. Line managers are responsible for knowing the whereabouts of their staff; discussing potential risks to their staff arising from lone working; and putting in place appropriate, pragmatic actions to mitigate those risks (see procedure below). All staff have responsibilities to take reasonable care of themselves and other people affected by their work activities and to co-operate with their employers in meeting their legal obligations.

7.	Development, approval, and implementation
7.1	This procedure will be: Developed by the Head of Governance and Assurance with the support and expert input of the SY&BCCG’s Health & Safety specialist Approved by the Health & Safety Group, which reports to the Audit Committee Disseminated to all CCG staff via email, staff bulletins, and the intranet.
8.	Procedure
8.1	Staff working alone in Hillder House
8.1.1	Staff working alone are at greater risk for a number of reasons: Persons attending work early in the morning are potentially at risk because they are the first to enter the site or building, which could expose them to either danger from a fault such as gas leak or electrical fault which has developed over night There is increased threat of personal attack from unauthorised persons on site If a lone worker suffered an accident while working alone in the building there is a possibility that they would not be discovered for some time.
8.1.2	In order to mitigate these threats the following steps should be taken: The worker should obtain their line manager’s agreement before working outside their normal hours The worker and their line manager should agree a procedure to allow the lone worker to be able to contact their line manager or a colleague in the case of an emergency When working late, the worker should inform their line manager beforehand if possible, and also when they leave the premises If the line manager is not available, the worker should inform another manager or colleague of what time they expect to finish work and inform them if there are any changes to those plans. When the worker has finished and is outside the building, they should inform their contact that they are done for the day.
8.1.3	Lone workers should always ensure they will be able to leave the office safely after working late. There have been instances where the building has been locked and people have been locked in.

8.2	Staff working alone at other locations
8.2.1	Lone workers must always ensure that CCG manager or appropriate colleague is aware of their planned movements. This means providing them with the address of where they will be working, details of the people they will be working with or visiting, telephone numbers if known and expected arrival and departure times.
8.2.2	Arrangements must be in place to ensure that if a colleague with whom details have been left leaves work, they will pass the details to another colleague who will check that the lone worker arrives back at their office/base or has safely completed their duties. Procedures must also be in place to ensure that the lone worker is in regular contact with their manager or relevant colleague, particularly if they are delayed or have to cancel an appointment.
8.2.3	When working at other sites lone workers should ensure they understand the local procedures for locking up, times etc. They should always ensure that they sign out of the building. If they must work late they should ensure that their presence is reported to the proper person and that security (if applicable) is aware of the arrangements.

8.3	Lone working and vehicles
8.3.1	Before setting out, lone workers should ensure that they have adequate fuel for their journey and give themselves enough time for the journey to avoid rushing or taking unnecessary risks.
8.3.2	Items such as bags or cases should never be left visible in the car. These should be out of sight, preferably stored in the boot of the vehicle.
8.3.3	Lone workers should always try to park close to the location that they are visiting and should never take short cuts to save time. At night or in poor weather conditions, they should park in a well-lit area and facing the direction in which they will leave. They should ensure that all the vehicle’s windows are closed and the doors locked.
8.3.4	In case of vehicle breakdown or accident, lone workers should contact their manager or colleague immediately. If they need to leave the vehicle to use an emergency telephone, they should put their hazard lights on, lock their vehicle and ensure that they are visible to passing traffic.

8.4	Escalation Procedure
8.4.1	Line managers must discuss with their lone worker staff what actions they should take in the event of an incident.
8.4.2	Where there is genuine concern, as a result of a lone worker failing to attend a visit or an arranged meeting within an agreed time, or to make contact as agreed, the manager should use the information provided to locate them and ascertain whether they turned up for previous appointments that day. Depending on the circumstances and whether contact through normal means can be made, the manager or colleague should involve the police, if necessary.
8.4.3	If it is thought that the lone worker may be at risk, it is important that matters are dealt with quickly, after considering all the available facts. If police involvement is needed, they must be given full access to information held and personnel who may hold it, that information might help trace the lone worker and provide a fuller assessment of any risks they may be facing.
8.4.4	It is important that contact arrangements, once in place, are adhered to. Many such procedures fail simply because staff forget to make the necessary call when they finish their work. The result is unnecessary escalation and expense, which undermines the integrity of the process.

9.	Monitoring the Compliance and Effectiveness of this Procedure
9.1	Compliance with, and effectiveness of, this procedure will be monitored by: Regular discussion and review by the Health & Safety Group Ongoing monitoring and review of incidents reported through the Safeguard incident reporting system.
10.	References
10.1	The Health & Safety Executive has provided guidance related to lone working in the following publication: Working Alone: Health and Safety Guidance on the Risks of Lone Working (http://www.hse.gov.uk/pubns/indg73.pdf).
11.	Review of the Procedure
11.1	The procedure will be reviewed at least every 2 years by the Health & Safety Group.

Appendix 4

Lone Worker Risk Assessment

The Health and Safety Executive (HSE) defines lone workers as:

“Those who work by themselves without close or direct supervision”

Further HSE definition examples include. Only one employee works on the premises, employees work separately from others and employees work outside normal hours

Area/Task:	Lone working risk assessment for NHS Barnsley CCG staff

Date: November 2016	Persons Assessing the Risks: IP

Ref No:	Activity/Task/Area	Hazard Identified	Likelihood 1 – 5	Consequence 1 – 5	Risk Rating	Controls in place (including PPE as a last resort)	Recommended Additional Controls	Post Risk Rating

Note:	You should rate the risks on the basis of the current controls in place

1	Working outside normal office hours within Hillder house	There is a lone working risk of not receiving help in the event of an injury while working alone. Any injuries suffered could be exacerbated due to no first aide cover. This could result in litigation.	1	3	3 Low	Lone Worker procedure Mobile phone	Ensure lines of communication are available to lone workers who work outside office hours, line managers / colleagues are aware that the building is occupied, mobile phone numbers provided in the case of an emergency Lone worker to phone colleague when leaving the building at night.	3
2	Evening work within Hillder house	There is a risk of setting off the burglar alarm and not being able to reset it, which could result in the police visiting the site due to staff being locked in the premises after hours.	1	2	2 Low	Lone Worker procedure Mobile phone	Ensure reception are aware that work is to be carried on after office hours, ensure the lone worker is aware of the procedure to set the alarm Ensure that a manager / colleague is aware the person will be on site	2
3	Working off site, within another building	There is a risk of staff being locked in with potentially no safe available means of escape due to late working at other sites, which could result in litigation.	1	2	2 Low	Meeting in diary, diary open to other staff Signing visitors sheets, Mobile phone	Advise staff to inform reception/ security that they plan to remain late if permitted. Ensure that a manager / colleague is aware the person will be on site	2
4	Travelling to and from meetings	There is a risk of injury to staff and others due to car incidents while travelling to and from other premises, which could result in litigation.	2	3	6 Med	Meetings in diary on outlook. Lone Worker Procedure. Mobile phone. Escalation procedure.	Conduct driving risk assessment and the development of a driving procedure. Be aware of your surroundings when driving, ensure your car is maintained and windows clean to aid visibility	3
5	There is a risk of injury due to Inclement weather while travelling to and from other premises, which could result in litigation.	2	3	6 Med	Check the weather forecast before travelling, if travel is required, it is advisable for warm clothes, food and a shovel is taken, ensure colleagues are aware, if there is an issue ensure your mobile phone is fully charged.	3
6	Walking from vehicle to meeting	There is a risk of injury due to slips, trips & falls while walking to or from a meeting, which could result in litigation.	2	2	4 Low	None	Ensure footwear is suitable when travelling. Always take your time, do not rush, park in well-lit areas were possible	2
7	There is a potential risk of physical / verbal aggression from members of the public while walking to or from a meeting, which could result in litigation and absence due to stress.	1	2	2 Low	None	Ensure personal items are not on show. Always park in well-lit areas were possible. Conflict resolution training could be delivered to front line staff	2
8	There is a risk of personal injury/suffering due to Inclement weather while walking to and from a meeting	1	2	2 Low	None	Check weather forecast before travelling, ensure clothing and footwear is suitable.	2
9	There is a risk of staff suffering from musculoskeletal issues from incorrect manual handling techniques due to carrying heavy bags for meetings which could result in long term illness and potential medical/legal costs to the business	1	3	3 Low	e-learning & practical manual handling training	Plan your meeting/journey ensure only work required is carried.	3

APPENDIX 5

Equality Impact Assessment 2013

Title of policy or service	Security Policy and Procedure
Name and role of officers completing the assessment	Richard Walker / Ruth Nutbrown
Date assessment started/completed	18/11/2016

1. Outline
Give a brief summary of your policy or service Aims Objectives Links to other policies, including partners, national or regional	To protect staff, property and assets from a security threat. Produced in line with NHS Protect guidance. The policy should be read alongside the CCG’s Corporate Manual; Fraud, Corruption, and Bribery Policy; Fire safety Policy; Health and Safety Policy; and Lone Worker Procedure.

2. Gathering of Information This is the core of the analysis; what information do you have that might impact on protected groups, with consideration of the General Equality Duty.
What key impact have you identified?	What action do you need to take to address these issues?	What difference will this make?
Positive Impact	Neutral impact	Negative impact
Human rights	Nil	Nil	Nil	N/A	No anticipated detrimental impact has been identified on any equality group. The policy is applicable to all employees and adheres to NHSLA Standards, statutory requirements and best practice and makes all reasonable provision to ensure equity of access to all staff.
Age	Nil Nil Nil	Nil Nil Nil	Nil Nil Nil	N/A
Carers	Nil Nil Nil	Nil Nil Nil	Nil Nil Nil	N/A
Disability	Nil Nil Nil	Nil Nil Nil	Nil Nil Nil	N/A
Sex	Nil Nil Nil	Nil Nil Nil	Nil Nil Nil	N/A
Race	Nil Nil Nil	Nil Nil Nil	Nil Nil Nil	N/A
Religion or belief	Nil Nil Nil	Nil Nil Nil	Nil Nil Nil	N/A
Sexual orientation	Nil Nil Nil	Nil Nil Nil	Nil Nil Nil	N/A
Gender reassignment	Nil Nil Nil	Nil Nil Nil	Nil Nil Nil	N/A
Pregnancy and maternity	Nil Nil Nil	Nil Nil Nil	Nil Nil Nil	N/A
Marriage and civil partnership (only eliminating discrimination)	Nil Nil Nil	Nil Nil Nil	Nil Nil Nil	N/A
Other relevant groups	Nil Nil Nil	Nil Nil Nil	Nil Nil Nil	N/A

Having detailed the actions you need to take please transfer them to onto the action plan below.

3. Action plan
Issues identified	Actions required	How will you measure impact/progress	Timescale	Officer responsible
No anticipated detrimental impact has been identified on any equality group. The policy is applicable to all employees and adheres to NHSLA Standards, statutory requirements and best practice and makes all reasonable provision to ensure equity of access to all staff.	There are no statements, conditions or requirements that disadvantage any particular group of people with a protected characteristic – therefore there is no required action identified.	The policy will be consulted on widely and will be monitored via the Equality and Diversity Steering Group/Management Team.

4. Monitoring, Review and Publication
When will the proposal be reviewed and by whom?	The policy will be reviewed 2 years after its implementation date.
Lead Officer	Richard Walker	Review date: November 2018

Once complete please forward to your Equality lead Elaine Barnes via email elaine.barnes3@nhs.net