CONTROLLED DOCUMENT

Security Policy (including The

Prevention and Control of Violence &
Aggression)

CATEGORY: Policy

CLASSIFICATION: Governance
PURPOSE To set out the principles and
framework for the management of
Security within the Trust, to ensure
that all staff understand their roles
and responsibilities.
Controlled Document 146
Number:
Version Number: 6
Controlled Document Director of Corporate Affairs
Sponsor:
Controlled Document Trust Security Management
Lead: Specialist
Approved By: Board of Directors
On: 28 July 2016
Review Date: July 2019
Distribution:
• Essential All Trust Staff
Reading for:
• Information for:

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Contents
Paragraph Page
1 Policy Statement 3
2 Scope 3
3 Framework 3
4 Duties 8
5 Implementation 12
6 Monitoring 13
7 References 13
8 Associated Policy and Procedural Documentation 13
Appendices
Appendix
Monitoring Matrix 15
A

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1 Policy Statement

1.1 The Trust is committed to providing a safe and secure environment for patients,
visitors, staff and all workers engaged within the Trust. In particular, the Trust will
not tolerate harassment, violence and/or aggression without lawful justification or
excuse.

1.2 The objective of this policy is to ensure that the Trust provides a secure and safe
environment which minimises security risks to all patients, staff and visitors alike
and also protects the property, assets, service delivery and the reputation of the
Trust so that:

1.2.1 There is a safe and secure environment with regards to persons,

functionality and physical assets;

1.2.2 There is a unified, structured and proactive approach to the management

of security and violence and aggression within the Trust with all due
consideration of legislative, regulatory and mandatory obligations; and

1.2.3 All persons are aware of their roles, responsibilities and obligations with
regards to security matters;

2 Scope

2.1 For the purposes of security this policy applies to all Trust staff, including
Contractors, Agency and Locum workers as well as those undertaking
secondments whether they are involved in Trust business whilst on any
property owned or controlled by the Trust or off Trust premises. Nominated
managers must therefore ensure that any non-employed workers are aware
of the requirements of this policy and the associated procedures and how to
apply them.

2.2 The policy is applicable in all of the following circumstances:

2.2.1 Violence from staff towards, other staff, patients and visitors/public

2.2.2 Violence from Patients to staff, other patients and visitors/public

2.2.3 Violence from Visitors/public to staff, patients and other visitors/public

2.3 Definitions

Within the context of this policy the following definitions, taken from NHS
Protect guidance, are used:

2.3.1 assault is described as `the intentional application of force against the

person of another without lawful justification, resulting in physical injury
or personal discomfort’; and

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 2.3.2 Verbal aggression is `the use of inappropriate words or behaviour
causing distress and/or constituting harassment`.

3 Framework

3.1 This section describes the broad framework for the Security Policy. Detailed
instructions are provided in the associated procedural documents.

3.2 The Director of Corporate Affairs shall approve all procedural documents
associated with this policy, and any amendments to such documents, and is
responsible for ensuring that such documents are compliant with this policy.

3.3 Security – General

In order to achieve a safe and secure environment for all, the Trust shall:

3.3.1 Ensure that risks are properly identified, assessed, and that
appropriate mitigation measures are put into place (“Security Risk
Assessments”) in accordance with the Security Procedure;

3.3.2 Make available appropriate resources to implement this policy

effectively. The Trust’s security service for the main sites is provided
by engie who have a dedicated security manager with overall
responsibility for engie security staff;

3.3.3 Clearly set out the responsibilities of staff at all levels;

3.3.4 Provide guidance on how to manage security issues and incidents;

3.3.5 Monitor the effectiveness of such measures taken and to make any
necessary amendments to policies and procedures;

3.3.6 Provide suitable support, advice and guidance to those involved and
exposed to security incidents; and

3.3.7 Sustain positive relationships with other key stakeholders e.g. law
enforcement organisations, neighbours, the National Counter Fraud
and Security Management Service, the Health and Safety Executive
and other regulatory bodies

3.4 Management of Violence and Aggression

For all incidents of violence and aggression the Trust will ensure, where
appropriate, that:

3.4.1 potential triggers to violence and aggression are risk assessed as part
of the security risk assessments;

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 3.4.2 reasonable measures to reduce the likelihood of violence and
aggression are devised and implemented to address specific risks;

3.4.3 consideration is given to excluding patients/public who present an

unacceptable risk in accordance with the Withholding Treatment
Procedure;

3.4.4 specialist advice on appropriate control mechanisms will be provided

by the Security Management Specialist and/or Health and Safety
Adviser;

3.4.5 support is provided to any member of staff involved in an incident of

violence or aggression;

3.5 Where staff are either violent and/or verbally aggressive the Trust’s
Disciplinary Policy will be followed.

3.6 Where a patient is subject to violence and or verbal aggression from another
patient and or a member of the public and it appears that there is a
safeguarding risk the Trust’s Safeguarding Processes shall be adhered to.

3.7 All incidents of violence and aggression will be reported to the Trust Security
Management Specialist and engie Security who will manage the incident.
Police should be informed should a criminal offence be committed and all
security involvement will be documented.

3.8 The instructions provided in the associated Security Procedure shall be

followed.

3.9 Major Incidents and Serious Threats

3.9.1 The Trust Major Incident Plan may be implemented in the event of a
major security incident. In such circumstances, this plan will
supersede or enhance the security measures outlined within this policy
and associated procedures.

3.9.2 Serious threats, including terrorist threats, to the Trust will be

assessed and appropriate measures will be implemented
commensurate with the nature and level of risk.

3.9.3 The implementation of general preventative measures will reflect the

five national levels of threat, ranging from low (i.e. unlikely attack) to
critical (i.e. expected imminent attack) and will include an increase in
the frequency of engie Security’s preventative patrols in the event of a
rise in the national threat level. The security patrols are to be recorded
in the security log.

3.9.4 If the Trust is advised by the County Terrorism Security Advisors of a

specific terrorist threat or other serious threat to the Trust or health

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 bodies generally, the Trust Security Management Specialist will inform
engie Security and engie will assess the individual risk and put in
place measures to counteract the risk.

3.10 Lock-down

A lock down procedure enables an entire building/site or parts of the

building/site to be locked down in the event of a serious incident. The TSMS
shall, in conjunction with engie Security where appropriate, ensure that a lock
down procedure is in place. Lockdown can only be authorised by the
Hospital On-Call Manager or the Major Incident Command Control Centre
Manager. The Trust’s Lock Down Procedure provides full details of the lock
down for each site.

3.11 Management of Security Incidents

3.11.1 The Trust will report any security incidents to engie and also report
details of the incident on the Trust incident reporting system. The
Trust and engie shall respond to all Security Incidents. The Trust shall
monitor engie level and nature of response to ensure that it is
appropriate to each particular security incident.

3.11.2 The incidents will be documented by engie and TSMS will be informed
on a weekly basis or, in the event of a Major Incident, as soon as
practicable.

3.12 Security of Trust Assets

3.12.1 All Managers are responsible for the safety and security of all Trust
assets within their area of responsibility. This responsibility includes
carrying out a local risk assessment and putting in place suitable
security measures for when the equipment is in storage.

3.12.2 Equipment must not be removed from its intended point of use or safe
storage without permission from a suitably authorised person.

3.12.3 All materials and equipment must be used, stored and maintained in
accordance with their intended purpose and manufacturer’s
recommended instructions.

3.13 Identification Badges and Access Control Cards

All Trust staff must display authorised Trust identity badges at all times when
on duty. Routine stop-checks will be undertaken by engie security. All staff
must comply with a request from security to show the officer identify badge.

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 3.14 Key Management

All Wards and Departments are responsible for implementing a safe and
secure system for the management of keys that are issued for their use as
part of local security procedures. engie will put in place a secure, robust and
fully auditable system for the management and distribution of keys used by
security, including master sets.

3.15 Termination of Employment

Upon termination of employment, Line Managers shall ensure that the

individual returns all Trust assets which will include: all equipment, uniforms,
ID badges, Access/Smartcards, keys and car parking permits. engie security
office must be informed to ensure that all access control permissions are
removed.

3.16 Lone Working

Nominated Managers shall be responsible for identifying any staff who are
subject to lone working and completing a risk assessment. They will develop
and agree suitable working practices, in accordance with the Trust Lone
Worker guidelines including the consideration to the issue of `Reliance` lone
worker alarms.

3.17 Intellectual Property and Security of Information

3.17.1 Staff are required to respect confidentiality of information and must

adhere to the Trust’s Information Governance Policy.

3.17.2 It is the responsibility of all staff to ensure that information is kept

secure.

3.17.3 Staff are required to comply with the Trust Information Security
Processes.

3.18 Security of Trust Vehicles

3.18.1 All vehicles owned or leased by the Trust must only be used by
authorised personnel and doors and windows locked when left
unattended. Keys must be in the possession of the driver at all times.

3.18.2 All items contained within a vehicle must be appropriately stored and
concealed from public view, so far as is reasonably practicable.

3.19 Car Parking

3.19.1 All vehicles parked on Trust property shall be at the owner’s risk and
the Trust will not be held liable for any damage, however caused.

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 3.19.2 All drivers are required to abide by the terms and conditions that are
contained within the Trust’s Traffic Management Policy

3.20 Waste and Hazardous Items

All waste including potentially hazardous items must be segregated, handled,

contained, secured and stored in accordance with the Trust’s Waste Policy
and its associated procedure.

3.21 Training

The Trust will ensure security and violence and aggression awareness
training, including conflict resolution training, is provided in accordance with
the Trust’s Training Catalogue (Training Needs Analysis).

4 Duties

4.1 Executive Director for Security Management

4.1.1 In accordance with the requirements of the Secretary of State for

Health, The Director of Corporate Affairs has been appointed as the
Trust’s Security Management Director (SMD). The post holder shall
act on behalf of the Board of Directors as the named Director with
overall responsibility for Security Management arrangements within
the Trust.

4.1.2 They shall provide assurance to the Board of Directors on compliance

with this policy and report any material failures of compliance or other
security concerns including violence and aggression.

4.2 Deputy Director for Corporate Affairs

The Deputy Director of Corporate Affairs shall have responsibility for the
planning and delivery of security management arrangements.

4.3 Trust Security Management Specialist

The Trust’s Security Management Specialist (TSMS) will be responsible for

co-ordinating and delivering a professional operational security management
service. In so doing, the post holder shall:

4.3.1 ensure that engie has completed a security risk assessment for all Trust
sites;

4.3.2 ensure engie carry out the site security risk assessments;

4.3.3 Provide specialist support, advice and assistance in relation to all

security and violence and aggression matters;

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 4.3.4 Develop and implement appropriate Trust-wide security policies and
procedures;

4.3.5 Monitor and support the development of localised operational security

procedures within all areas of the Trust;

4.3.6 Act as the main point of contact with the National Counter Fraud &
Security Management Service, law enforcement agencies and other
such organisations;

4.3.7 Monitor security equipment to ensure that it is functional and

appropriately maintained;

4.3.8 Liaise with the Police where necessary and to provide information on
identified perpetrators of violence and other crime;

4.3.9 Collate and analyse reported security incidents, identifying trends in the
interventions required of security staff in respect to all security incidents
including violent incidents; and

4.3.10 Advise on the availability and use of `Reliance` lone worker alarms.

4.4 Senior Divisional and Corporate Directors/Managers (Including

Directors of Operations and Associate Directors of Nursing)

Senior Divisional & Corporate Directors/Managers will be responsible for

ensuring that this policy and associated practices, as well as local security
procedures are developed, implemented and effectively managed within
each of their areas of responsibility. They will ensure that each department
under their control undertake a security risk assessment, including the
potential for violence and aggression, implement controls where risks are
identified and monitor these for effectiveness.

4.5 Heads of Departments, Group Managers and Matrons and Nominated

Managers

All Heads of Departments, Group Managers and Matrons and Nominated

Managers are responsible for:

4.5.1 ensuring local security procedures are in place;

4.5.2 undertaking a comprehensive departmental risk assessment and

creating an environment and climate where violence is less likely;

4.5.3 ensuring that the Policy, the associated Procedures, guidelines and
are made known and available to all their staff;

4.5.4 supporting any member of staff who has been involved in any security
incident including violence and aggression;

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 4.5.5 ensuring that an online Datix Incident Report Form is completed for
every security incident including violence and/or aggression and the
Trust Security Management Specialist together with the Health and
Safety team is informed; and

4.5.6 Prevention, control measures and monitoring arrangements are

implemented;

4.5.7 All staff are made aware of their obligations and receive appropriate
education, training and development.; and

4.6 Ward/Departmental Managers and Supervisors

Ward/Departmental Managers and Supervisors will be responsible for

ensuring that Security policies, practices and procedures are complied with,
which shall include:

4.6.1 Ensuring that local security procedures are adhered to and that all
actual or potential breaches, acts of assault, violence or aggression
are reported using the Trust incident reporting system and action plans
devised as required;

4.6.2 ensuring that all security equipment is fully functional and reporting
any faults to engie helpdesk;

4.6.3 Ensuring that all Trust assets, property and information are not left
unattended and are correctly and securely stored at all times;

4.6.4 Ensuring that the department is kept secure and locked when
unattended;

4.6.5 Ensure that all patients are made aware of the risks associated with
bringing in large amounts of money or valuables into the Trust and
where this responsibility is delegated to staff that the patient property
guidelines are followed.

4.7 All staff

All staff are responsible for assisting and supporting in the provision of a
secure and safe environment and to this aim they must:

4.7.1 Comply with this policy and associated procedures, including local
security arrangements;

4.7.2 Maintain a high degree of vigilance and not undertake any actions that
may compromise their own personal safety, or that of colleagues,
patients or visitors;

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 4.7.3 Routinely assess potential and actual security risks and report any
concerns to their Line Manager;

4.7.4 Attend relevant security training and awareness sessions;

4.7.5 Report any malfunctioning of security equipment at the earliest

possible opportunity, using the engie helpdesk;

4.7.6 Not interfere with or misuse any security equipment, property or the
environment as a whole;

4.7.7 Ensure that they wear an authorised Trust ID badge, in a visible

position at all times;

4.7.8 Challenge any persons not known to them and not wearing an
authorised Trust ID badge;

4.7.9 Ensure that Trust assets are not removed from their intended location
without appropriate authorisation;

4.7.10 Ensure that their personal property is kept secure at all times;

4.7.11 Try to de-fuse violent/aggressive situations if they feel safe to do so

and immediately summon assistance when aware of a potential or
actual violent incident;

4.7.12 If involved in an incident either as a victim or when going to someone’s

assistance, use the minimum of force necessary to control the violent
person(s) bearing in mind the legal/medical constraints and personal
responsibility to act within the law; and

4.7.13 Complete an online Datix Incident Report Form immediately following

such an event or as soon as possible thereafter.

4.7.14 Compliance with this policy and associated procedures is mandatory

and failure by any member of staff to comply with such requirements
will result in consideration of the use of disciplinary action.

4.8 Trust Health, Safety and Environment Committee

The Trust Health Safety and Environment Committee regularly assesses and
reviews security activity, trends, risks and issues across the Organisation as
a whole. The Committee recommends the development of action plans by
the TSMS with a view to mitigating or eradicating such risks. The Chair of
the Committee reports to the Trust Board.

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 4.9 Divisional and Corporate Consultative Committees

4.9.1 The Divisional & Corporate Consultative Committees act as a local

forum for reviewing local security activity, trends, risks and issues.

4.9.2 The Chair of each Committee report to the Trust Health, Safety and
Environment Committee through the Directors of Operations and the
Trust’s Security Management Specialist.

4.10 Security and Estates Management

Security and Estates Management is provided by engie The Manager of

engie will ensure that:

4.10.1 All site security risk assessments are completed in accordance with
the their contract with the Trust;

4.10.2 a secure, robust and fully auditable system is established for the
management and distribution of keys used by security, including
master sets;

4.10.3 engie undertake lock and unlock procedures for designated Trust
premises. This includes promptly attending and assessing premises
where a breach of security has been reported;

4.10.4 A method statement outlining engie service provision is produced

annually

4.10.5 Ensure that all security equipment is fully functional

4.10.6 Respond and assist with potential and actual security incidents,
including acts of assault, violence and aggression;

4.10.7 provide continuous surveillance of security monitoring systems and

undertake regular patrols (as defined within engie method statements)
of Trust premises and grounds with a view to identifying potential risks
and resolving any actual breaches of security; and

4.10.8 Investigate any breaches of security and report the finding to the Trust
Security Management Specialist.(TSMS)

5 Implementation

5.1 This policy will be implemented by all levels of management in the Trust and
made available to all staff via the Trust intranet.

5.2 In addition, information on security issues will be provided to wards and

departments by the TSMS to encourage a pro-security culture among staff.

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 5.3 The TSMS will provide advice, assistance and support on various security
related matters

5.4 Security awareness will be included as part of Trust induction with additional
training sessions made available to staff as required.

6 Monitoring

The standards to be achieved and the monitoring arrangements to ensure

compliance are detailed at appendix A.

7 References

7.1 Secretary of State’s Directions for Violence & Aggression and Security
Management (2003 / 2004).

7.2 Health and Safety at work Act 1974

7.3 The Management of Health and Safety at Work Regulations 1999

7.4 The Corporate Manslaughter and Corporate Homicide Act 2007

7.5 The Civil Contingencies Act 2004

7.6 NHS Litigation Authority

7.7 The Management of Health and Safety at Work Regulations Working Alone
in Safety (HSE) Publication

7.8 Data Protection Act 1998 (CCTV)

8 Associated Policy and Procedural Documentation

8.1 Withholding Treatment Procedure for Aggressive Patients

8.2 Lone Worker Guidelines

8.3 Security Procedure

8.4 Disciplinary Policy

8.5 Information Governance Policy

8.6 Traffic Management Policy

8.7 Major Incident Plan

8.8 Lock Down Procedure.

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 8.9 Trust Waste Policy

8.10 Training Catalogue (Training Needs Analysis)

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 Appendix A Monitoring Matrix

MONITORING OF MONITORING REPORTED TO MONITORING PROCESS MONITORING

IMPLEMENTATION LEAD PERSON/GROUP FREQUENCY
Monitoring of secure environment
a) Duties
Trust Security Management TSMS By exception to TSMS Weekly,
Specialist (TSMS) will ensure that: TSMD • Monthly Audit of engie risk monthly or
• engie has completed security assessments (all risk annually (see
risk assessments assessments saved in evidence monitoring
folder) process)
• Police is informed of identified • Monthly meetings of TSMS with
perpetrators of crime the police to discuss any security
incidents (any necessary actions
are followed up by email - email
• Security incident trends are evidence available upon request)
detected • Weekly meetings of TSMS with
engie staff to discuss any security
incidents (any necessary actions
are followed up by email - email
• Departments (Nominated evidence available upon request)
Managers) have completed • Annual check of departmental
their risk assessments and risk assessments and local
have local security procedures procedures. Any updates are
in place then fed into the central database

Trust Health, Safety and Trust Health, Safety and Environment

Environment Committee Committee
• assesses and reviews security • Minutes/Reports of meetings Every quarter

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 activity, trends, risks and issues (quarterly)
across the Trust every quarter

b) Risk assessments of physical security or premises and assets

• engie carry out yearly risk engie • TSMS • Yearly audits of engie risk
assessments of premises assessments of premises by • Annually
TSMS saved electronically.
• Departmental security risk • Departments • TSMS • TSMS collates all departmental
assessment of assets risk assessments of assets and
feeds information into a Trust
wide database (saved in
evidence folder)
c) and d) Development and Following up of Actions Plans
TSMS develops and follows up any TSMS TSMS reviews any outstanding actions Weekly
actions by email as immediate on a weekly basis (email evidence
response is required. Datix is updated available upon request).
as and when required.

e) Overall compliance monitoring

Monitoring of the Security service TSMS PFI Performance engie send monthly reports containing Monthly
provided by engie Manager security responses to incident reports to
the TSMS. The TSMS then ensures
compliance with the PFI security
contract. Any event failures are
reported to the PFI Performance
Manager via email as an immediate
response is required.

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Monitoring of Trust security incidents TSMS Trust Health, Safety The Trust Health, Safety and Every quarter
and Environment Environment Committee assesses and
Committee reviews security activity, trends, risks
and issues across the Trust every
quarter. These meetings are minuted.

Monitoring of all Trust security issues TSMS NHS Protect TSMS reports all Trust security issues to Annually
NHS Protect.

Monitoring of violence and aggression (including lone workers)

a) Duties
TSMS will: TSMS
• Advise on availability and use of • Reliance • TSMS • Monthly
• Reports from Reliance to TSMS
‘Reliance’ Lone worker alarms. • TSMS • NHS Protect • Annually
• Violence and Aggression
• Monitor any trends in violence statistics submitted to NHS
and aggression compared to Protect by TSMS
other Trusts.

Trust Health, Safety and Quarterly

Trust Health, Safety and Environment
Environment Committee will:
Committee
• Consider completed security Minutes/Reports of meetings (quarterly)
risk assessments (including
violence and aggression) and
agree action plans and
appropriate control measures

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 to reduce risks to the lowest
possible level.

b) and c) Risk assessment for prevention and management of violence and aggression, including timescales
Risk assessments for the prevention Departments TSMS TSMS collates all departmental risk Monthly
and management of violence and (Nominated assessments (including violence and
aggression, including lone workers Managers) aggression and lone workers) and feeds
information into a Trust wide database
(saved in evidence folder).
d) and e) Development and Following up of Action Plans
See above – duties – Trust Health, Mins of Trust Health, Safety and Quarterly
Safety and Environment Committee Environment Committee

Staff involved in incidents of violence Occupational Health Head of Health and Records held by Health and Safety. Ad hoc
will be provided with both and Safety Safety Department.
psychological and practical support as Department
required.

f) Arrangements for lone workers

The Trust ensures the safety of lone Reliance TSMS The TSMS receives a report from Monthly
workers by giving them access to a Reliance on the availability and use of
bespoke alarm system lone workers alarms (see duties above)
g) Training
Training is delivered by the TSMS (in TSMS Executive Director Compliance with training is monitored Monthly
accordance with the TNA) of Delivery via the dashboard which provides live
data. The TSMS will check the
dashboard data on a monthly basis to
check overall compliance by

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 department. Any trends are picked up at
Strategic Delivery Group meeting which
is chaired by the Executive Director of
Delivery. This meeting is minuted.
h) Overall compliance
TSMS will monitor any trends in TSMS NHS Protect TSMS will submit Violence and Annually
violence and aggression compared to Aggression statistics to NHS Protect
other Trusts (see duties).

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