HSPOL02 VIP Policy v3 by Provide Community

VIP Management Policy

Version: V3

Ratified by: Finance and Investment Committee (FIC)

Date ratified: 25/05/2022

Job Title of author:

Health, Safety, Fire and Security Manager –Estates and Facilities

Reviewed by Committee or Expert Group Property Health and Steering Group

Equality Impact Assessed by:

1. Introduction

Should a Category One or Two VIP attend site as an emergency via ambulance or self-presenting, there may not be prior notification. It is vital that there is a process to follow as soon as staff become aware of any patient’s actual or potential VIP status. Immediate confidentiality and security are the first immediate steps to be followed.

2. Purpose

In order to co-ordinate organisational wide collaboration, this document sets out the appropriate procedures to be followed in keeping all staff informed of visits to the sites by very important people (VIP’s) and guests including royalty, government ministers, celebrities, dignitaries from home or abroad and other significant members of the community. This policy also advisesof the appropriate protocol to be followed for those who choose to visit those VIPs stated above.

Definitions

There are two categories of VIP described in this document:

Category One: Principal VIP (Royal family)

Category Two: Other VIP (government ministers, celebrities, dignitaries from home or abroad and other significant members of the community)

4. Duties

Group Chief Executive

The Group Chief Executive is responsible for ensuring that process are in place to ensure that the recommendations arising from the Kate Lampard report “Themes and lesson learnt from NHS investigations into matters relating to Jimmy Saville” (February 2015) are fulfilled and monitored.

This responsibility may be dissolved to the Security Management Director (SMD), Health, Safety, Fire and Security Manager (HSFS)

The HSFS is there to provide support during visits / admissions as agreed with the SMD. Together they will carry out risk assessments prior to the visit / admission or liaise with local Police or protection officers. Assessment will determine the appropriate level of additional resource or control measures if required. Risk assessments should include the likelihood of uninvited photographers and followers or fans potentially attracted by the presence of a celebrity or VIP.

If disruption to hospital or clinic business is judged likely, then senior staff may advise that the visit is inappropriate, suggesting a postponement or cancellation. This would need to be approved by the SMD.

All staff

All staff must act in accordance with policy and support visits to their areas by representing the organisation properly and acting professionally at all times.

The policy requires that approved official visitors are always accompanied by a member of staff throughout their visit to the organisation, as VIP’s / celebritiesare often accompanied by colleagues or friends, this applies to all supervising and chaperoning.

If approved official visitors are frequent visitors to the organisation e.g. a celebrity is linked with a particular service or a celebrity volunteer, and they are likely to be unaccompanied, advice will be sought from the Head of Safeguarding about what checks or authorisations will be required and Human Resources advised.

Any requests for celebrity, VIP or media visits must be referred to the HSFS. They will in turn notify the necessary parties of this request.

Visitor supervision can be delegated to clinical teams if appropriate, with a recommendation that at least one person is responsible for supervision and chaperone – with more chaperones required if the visiting party is larger.

If visits occur outside normal working hours and especially at weekends, the person leading the visit must notify the HSFS or Manager on Call (if out of hours) to reassure them that the visit is approved, advise of the arrangements and confirm that they will be supervising the visit.

5. Consultation and Communication

All staff must act in accordance with policy and support visits to their areas by representing the organisation properly and acting professionally at all times.

6. Monitoring

This policy will be reviewed every 2 years or any significant changes, lessons learnt.

7. Arranging a Visit

All visits should be notified to the HSFS

A central register of visitors will be maintained by the HSFS. For locally arranged or supervised visits, a member of the organising team will ensure that appropriate details of the visit are notified to the HSFS for recording, using appendix A of this policy.

Before authorising a visit to the organisation by a celebrity / VIP, the HSFS will check with the Communications Team, and the clinical service(s) that will be visited to ensure they feel the visit is appropriate.

The HSFS will alert the relevant member of the Executive Team (SMD) to all planned celebrity / VIP visits as soon as details are known, as it is likely the organisation would wish to ensure that one or more of the Executive Team are present at the visit.

Upon arrival at premises, the approved official visitors will be met by a representative for Provide. This could be a member of the Communications Team, local clinical team leader or an Executive Director. The organisation’s representative will ensure the visitor is logged with the HSFS

An organisation’s representative who will normally be a member of the Communications or local clinical leader, should remain with the approved visitor throughout the visit until they are escorted from the building.

Approved visitors who do not have appropriate checks and authorisation must not be left unaccompanied. In addition, any time they are in the patient’s room there will be a chaperone who will be a member of staff appropriate to the clinical setting.

The organisation’s representative will ensure that all appropriate ward / clinic protocols including infection prevention and control are observed by the VIP or celebrity visitor.

8. Emergency Procedures

Should a Category One or Two VIP attend site as an emergency via ambulance (highly unlikely) or self-presenting, there may not be prior notification. It is vital that this process is followed as soon as staff become aware of any patient’s actual or potential VIP status. Immediate confidentiality and security are the first immediate steps to be followed.

The notification of any VIP must be made to the HSFS, or Senior manager on call (if out of hours) at the earliest possible time, using the on call procedure, who will coordinate the management of the VIP as directed in the following sections of the policy.

Notification

The following table shows the individuals and processes involved in notifying the organisation of the imminent referral of both Category One and Two VIPs:

Category One (Principal VIP)

• Physician to the Queen and Consultant Nephrologist at the Royal Free Hospital (or deputy), Physician to the Royal Household and Consultant Physician at St Mary‘s Hospital

• Our Consultant will have to notify the GP at Sandringham or the Personal Protection Officer (depending on reason for referral) of the arrival of a Principal VIP via Papworth Switchboard 01480 830541.

The senior nurse will alert the HSFS or Senior Manager on-call, who will then

Category Two (Other VIP)

• The senior nurse will alert the HSFS or Senior Manager on-call, who will then notify the Executive Director on call and convene the internal incident Management Team as required.

notify the Executive Director on call and convene the internal incident Management Team as required.

Category One (Principal VIP)

Category Two (Other VIP) Registration on Arrival:

On arrival the VIP should be afforded a pseudonym, which should also be placed on the white board.

Sets of notes containing the alias and hospital number should be held in the Ward Office.

Out of Hours:

Electronic notes/images should only be held in a secure area

Patient Accommodation:

VIP’s will be provided with a room and en-suite facility close to Nurses Stations. Rooms identified include:

Side Room 1 – St. Peters Hospital

Security:

Lockdown procedures for the receiving ward should be instigated where required, in liaison with the HSFS in attendance.

Royal Staff and Security:

Accommodation will need to be identified for the Royal Physician(s).

Registration on Arrival:

On arrival the VIP should be afforded a pseudonym, which should also be placed on the white board.

Routine admission procedure will be followed unless deviations are requested by any security support.

Patient Accommodation:

VIP’s who wish to be moved to the private room at a point in care should discuss with their consultant, who will then activate the appropriate procedures via the senior Nurse in Charge

Transportation

Due to the challenges of entering the various sites that Provide work from access control and cordons will be put in place and these will be arranged prior to the time of the visit and in discussion with all necessary security personnel.

Security

Security issues in the management of VIPs are critical. Category One VIPs will normally be escorted by their own security team and they will want various information from the organisation as part of their own security management briefing, they may also direct the organisation to make some alternative arrangements during the course of a VIPs visit.

The following table summarises the organisational security procedures and protocols.

Category One (Principal VIP)

• A Principal VIP will provide his/her own security, including the Police. Liaison with the organisation’s HSFS and porters are essential at the earliest opportunity. Maps and other relevant plans will need to be provided for the security team.

• Lockdown may be required in wards

• Secure storage will be supplied for patient notes within the ward.

• Extra support for porters will be required and additional staff may need to be considered.

• Communication on radio frequencies and mobile phones is to be kept to a minimum.

• Master swipe cards may need to be afforded to the security staff of the Principal and the Royal Physician(s). These are available from NHS Property Services or Provide via the HSFS

• Staff should be reminded at the earliest opportunity to ensure they carry their ID badges with them at all times and not to discuss the presence of a Principal outside of work.

• Senior Nurse in charge will be asked to prepare an on-going list of in-patient names and scheduled visitors (within confidentiality guidelines) to be verified by the security liaison team.

Communications

Category One (Principal VIP)

• Outside lines may need to be restricted with access controlled via Reception

• A secure outside line will need to be afforded to the Principal VIP.

• Staff should be reminded to restrict all phone transmissions to an operational minimum.

• In order to maintain command and control, all non-clinical decisions must only come from Manager on call or Executive on-call. The Manager on call / HSFS will endeavour to keep all staff informed, as and when required.

Category Two (Other VIP)

• Where a VIP has provided their own security, liaison with the organisation’s HSFS and porters are essential at the earliest opportunity. Maps and other relevant plans will need to be provided dependent of the security risk of the VIP at the earliest opportunity.

• Police will be notified as appropriate.

• Lockdown may be required in wards

• Secure storage will be supplied for patient notes on within the wards.

• Communication on radio frequencies and mobile phones is to be kept to a minimum.

• Dependent on the level of security required for the VIP, master swipe cards may need to be afforded to the security staff of the VIP. These are available from NHS Property Services or Provide via the HSFS

• Staff should be reminded at the earliest opportunity to ensure they carry their ID badges with them at all times and not to discuss the presence of a VIP outside of work.

• Senior Nurse in charge may be asked to prepare an on-going list of inpatient names and scheduled visitors to be verified by a designated individual

Category Two (Other VIP)

• Outside lines may need to be restricted with access controlled via Reception

• Dependent on the level of security required for the VIP a secure outside line may need to be afforded to the patient.

• The Porters should be reminded to restrict all phone transmissions to an operational minimum.

• In order to maintain command and control, all non-clinical decisions must only come from Manager on call or Executive on-call. The Manager on call will endeavour to keep all staff informed, as and when

• That where possible, the next of kin (NOK) rings in at a particular time of day, speaks to the nurse in charge only, and that passwords are agreed with the NOK to verify identity required.

• That where possible, the next of kin (NOK) rings in at a particular time of day, speaks to the nurse in charge only, and that passwords are agreed with the NOK to verify identity

Media

The media interest for many VIPs can be intense. The principle of informing the media appropriately can assist in reducing covert media activity, however reputation and security risks should be managed.

The table below contains the organisation’s media considerations and procedures.

Category One (Principal VIP)

• All staff should be reminded at the earliest opportunity not to talk to the media or persons unknown.

• Our Communications Team will liaise with the Principal’s press representatives.

• Press releases should be agreed in advance with the Principal’s press representatives.

• Press releases will be managed by Communications Team under guidance from Manager on call. Provide may need to liaise with the CCG and/or Public Health LAT dependent on the nature of the situation.

• Internal communications should manage the distribution of information to staff on a daily basis.

• Provide Communications should manage the media, providing a secure location with regular updates. The media must be briefed on where they can and cannot go and reminded of the trespass laws with respect to NHS property.

Discharge

Category Two (Other VIP)

• All staff should be reminded at the earliest opportunity not to talk to the media or persons unknown.

• Our Communications Team will liaise with the VIP press representatives.

• Press releases will be managed by the Communications Team under guidance from the Manager on call. We may need to liaise with the CCG and / or Public Health LAT dependent on the nature of the situation.

• Internal communications should manage the distribution of information to staff on a daily basis.

• Provide Communications should manage the media, providing a secure location with regular updates. The media must be briefed on where they can and cannot go and reminded of the Trespass laws with respect to NHS property.

The discharge of VIPs needs to be managed just as sensitively as admission and their stay. The table below contains the discharge protocols and procedures.

Category One (Principal VIP)

• On discharge, documentation and correspondence will be given to the Royal Physician where appropriate. Any clinical notes which need to remain with Provide for further use

Category Two (Other VIP)

• The usual discharge process will be followed unless there are any specific requests depending on the VIP.

will be secured in a secure area, the location of which can be identified through the Executive team.

• All electronic notes / images should be secured in the relevant safe haven of the software. Any backup should be disposed of, or transferred to the safe haven of the software or CD / encrypted memory stick at the earliest opportunity.

• The discharge should be carefully managed with the attending physician and security team.

• Stand down will only be given by Manager on call or Executive on-call and only once the Principal VIP has left the property and the liaison teams have agreed it is safe to do so.

• A debrief will be held at the earliest opportunity following stand down to ensure that any learning is captured and this procedure is updated.

• If applicable, CCTV footage may need to be quarantined or run out through its due course.

Miscellaneous

The table below contains miscellaneous considerations and protocols.

Category One (Principal VIP)

The following support agencies may need to be considered by Manager on call and Executive on-call team:

• Refreshments / food

• Accommodation

• Locations for the media, Police, VIP entourage (adjoining rooms where available), ambulance team, volunteers (Restaurant). A member of staff will be allocated to liaise with these groups and report back to the Manager on call

• On-call staff being contacted to provide extra support. (e.g. Loggist, medical staff, pharmacist).

• Consumables (e g. linen, cutlery and china, TV).

Category Two (Other VIP)

The following support agencies may need to be considered by Silver command and Executive on-caller:

• Refreshments / food

• Accommodation

• Locations for the media), police, VIP entourage (adjoining rooms where available), ambulance team, volunteers (Restaurant). A member of staff will be allocated to liaise with these groups and report back to Silver command.

• On-call staff being contacted to provide extra support. (e.g. Loggist, medical staff, pharmacist).

• Consumables (e.g. linen, cutlery and china, TV)

9. Reporting Concerns

If during a VIP/celebrity visit, the behaviour of a visitor or a member of their accompanying party gives cause for any concerns whatsoever, then this should be raised at the time with the member of staff who is supervising them and visit brought to an immediate end.

Any serious incident must be reported to the HSFS and recorded on Datix.

10.Confidentiality & Consent

Prior to all approved visits, visitors will be informed by the Communications team of the appropriate confidentiality and consent requirements for patients and staff as well as for themselves, and will be expected to abide by them during and after the visit. This includes obtaining appropriate consent for all images, still and moving, for use in all media, including social media, to protect patient, staff and approved visitor identity.

Any patients who may be involved in a VIP/celebrity visit, e.g. they are an inpatient on a ward being visited, will be asked in advance of the visit whether they mind being potentially approached by the visitor. If there is likely to be photography, the patient will be asked if they consent to be photographed and will be requested to sign a photograph release form.

Staff are representatives ofthe organisation and are expected to behave professionally at all times. During VIP and celebrity visits, staff should continue in their roles as usual while supporting the management of the visit where appropriate. However staff have a right to refuse to be recorded on any photographic media without supplying a reason.

Approved official visitors to ward areas should always be greeted appropriately by staff and treated respectfully throughout their visit. Staff must not approach celebrities onwards, in corridors or other areas of the hospital.

11.Breach Reporting

If a VIP or celebrity attends the organisation without any prior notice and is not on a private visit to see a relative or friend who is a patient, the HSFS should be notified immediately in standard working hours.

If visiting is out of hours, this should be the Senior Manager on Call or Executive Director on Call. The visitor should be held in reception/nursing station until the senior nurse in charge is able to determine the nature of their visit and whether it is appropriate to go ahead.

Any member of staff concerned must comply with the organisation’s Incident Policy and a DATIX proforma must be completed.

12.Governance

Data Protection

Provide is required to fully support the principles of corporate governance and recognise public accountability, it also places importance on the confidentiality and security arrangements to safeguard, personal information about patients, staff and any commercially or security sensitive information.

It is important to recognise that some VIP’s being treated within the organisation may not appear to be high profile to some staff or even acknowledged as a VIP within the context of our national recognition. It is therefore imperative to recognise the potential sensitive nature, security and confidentiality needs of all notified VIP’s, no matter of any personal recognition by staff.

All staff must maintain confidentiality at all times in line with the organisation’s Confidentiality code of Conduct policy for staff. Failure to do so can result in disciplinary action.

Risk Assessment

A generic risk assessment for VIPs should be completed and updated prior to or in the course of each new VIP visit.

Staff

Only Provide contracted permanent staff will be allocated responsibility for the care and security of VIPs. These will normally be identified by the management team and will not include any unknown temporary or agency staff.

Gifts

Gifts for a VIP can constitute a major problem for the organisation, from a standpoint of volume of incoming gifts from ‘well-wishers’ however this poses a very high potential security risk.

A method of dealing with VIP gifts will need to be discussed with the relevant security authorities and VIP representatives at the earliest opportunity.

Some VIP Patients will offer gifts to staff. Staff should be reminded about the protocols following the offer of a gift from a patient or relative.

Language, Culture & Special Requests

The general principle governing special requests is to be prepared to grant reasonable requests, but service leadsshould enquire with the VIP’s representativesahead of time for some indication as to what special-needs requests may be required.

Monitoring effectiveness of this procedure

Following the discharge of a Category One (Principal VIP), debrief will be held at the earliest opportunity following stand down to ensure that any learning is captured and this procedure is updated if required.

Appendix: 1 – Visitor Registration Form

Any requests for celebrity, VIP or media visits must be referred to the Accredited Security Management Specialist (HSFS) who will advise on the arrangements. Please complete the details below.

PRE VISIT

Visitor name

Organisation

Date of visit

Times / duration of the visit

Location (s) of the visit

Purpose of the visit

Clinical lead (e.g. ward manager) who has approved the visit

Executive lead who has approved the visit

Schedule/itinerary of the visit

Name(s) of personnel (visitors) accompanying the visitor

Name of Provide staff supervising the visit

POST VISIT

Names of patients the visitor spent time with?

Did the patient(s) consent to photography?

Were consent forms completed?

This form should be completed and returned to the Health, Safety, Fire and Security Manager.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

VIP Management

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

Policy to outline the process to be followed when VIP/Celebrities are admitted or visit the site.

Project/Policy Manager: Health, Safety, Fire and Security Manager Date: May 2022

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Neutral

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Neural

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to addressparticular issues, including any consultation with staff or external groups/agencies.

Neutral

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

N/A

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

N/A

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

N/A

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

N/A

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

N/A

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

N/A

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised. It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative. The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action. If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.disabilitynow.org.uk – online disability related newspaper www.womenandequalityunit.gov.uk – Gender issues in more depth www.opportunitynow.org.uk - Employer member organisation (gender) www.efa.org.uk – Employers forum on age www.agepositive.gov.uk – Age issues in more depth

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage One: ‘Screening’