HSPOL20 Managing Patient Valuables -v4 by Provide Community

Managing Patient Valuables in Community Hospitals

Version: V4

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 Dept

Reviewed by Committee or Expert Group Property Health and Steering Group

Equality Impact Assessed by:

1. Introduction

This policy sets out the process for dealing with patient’s valuables whilst in one of the three community hospitals managed by Provide, on discharge or in the unfortunate event of their death. The safe storage of patient’s valuables is important to the organisation and so this policy forms part of an agreed system of control and provides an effective methodology for implementing controls.

2. Purpose

Once patients have handed over valuables to ward nursing staff, the senior nurse in charge is responsible for ensuring that this policy is adhered to and that appropriate action is taken to ensure safe storage of valuables and / or that valuables is returned to the patient or their relatives.

This policy applies to all patients admitted to one of our community hospitals

3. Definitions

This is not an absolute definitive list but the likeliest items that would be covered by this policy are:

• Money

• Jewellery

• Watches

• Bank cards

• Cheque books

• Pension books

• Telecare equipment

Duties

CEO, Health and Chief Nurse is responsible with ensuring that CQC Outcome 7: Safeguarding people who use services, specifically relating to security for patient valuables, is followed and maintained.

Director of Nursing and Allied Health Professional has overall responsibility for ensuring that the policy in rolled out across the inpatient wards and that the Senior Nurse in Charge has disseminated to all staff.

Senior Nurse in charge

The senior nurse in charge has overall responsibility to ensure that their teams are aware and follow this policy. Within all ward areas, ward safe checks are to be completed regularly. Written evidence of those checks is recorded for audit trail.

The senior nurse in charge is responsible for ensuring that ward staff are trained to implement this policy.

The senior nurse in charge is responsible for the appropriate management of patient valuables.

Nursing Staff

All nursing staff at all grades are responsible for ensuring that patient valuables are safe and kept in the safe with clear documentation in the valuables book.

The staff member will provide any support and advice that may be required by the senior nurse in charge in the implementation of this policy.

Accredited Local Security Manager (ASMS)

The ASMS is responsible to investigating any incident relating to the theft of patient valuables which are held under the responsibility of Provide.

It may be necessary to contact the Police, Provide’s Counter Fraud and Human Resources if it felt a crime has been committed and the responsibility falls with the ASMS to undertake this.

5. Consultation and Communication

This policy applies to all ward nursing staff

6. Monitoring

The following arrangements will be made to monitor the effectiveness of this policy:

• An un-announced audit may be carried out by the organisation’s ASMS to ensure that all patient valuables and valuables are safe.

• Incidents and Complaints regarding patient’s valuables will be monitored in accordance with the organisations Incident reporting and Complaints policies with data available for review at Quality & Safety Committee Meetings.

• Where the audit identifies deficiencies actions will be identified and implementation monitored by the senior nurse in charge with support from the Executive Clinical and Operations Director.

7. Ward Admission and Transfers Between Wards or Hospitals

During Office Hours

If a patient has valuables, these should be checked by TWO ward members of staff and listed on the Patient Valuables Records when the patient is admitted to the Ward. The valuables should be placed in a patient’s valuables envelope.

The staff member(s) admitting the patient shall either:

• Ask if the patient wishes to keep the valuables in the bedside locker, explaining that the organisation is not liable for any patient’s valuables and ensure that a disclaimer is signed (see Appendix 1); or

• Explain to the patient that their valuables could be placed in either the Ward safe overnight (if admitted out of hours) or the main hospital safe (where applicable).

• Ensure that when valuables is taken for safe keeping a record is made in the valuables book of where the valuables has been stored.

• Ensure where possible that the patient signs the valuables book

• Ensure the patient completes a disclaimer form and a copy is scanned into the S1 record.

If the patient wants the valuables put into the main safe the procedure is:

• The valuables must be checked by TWO ward members of staff.

• The valuables must be recorded in the ward valuables book.

• The valuables are then placed in the patient’s valuables envelope and all the patient’s details and contents should be clearly documented.

• The corresponding number from the valuables book should be entered on to the patient’s valuables envelope.

• The valuables and the valuables book should then be taken to the office for safe storage.

Copies of valuables book should be distributed as follows:

White Copy

To be kept by the Patient or Next-of-Kin

Pink Copy

To be kept in the Patient’s notes, which can be scanned into the S1 record.

Green Copy

To remain in valuables book until signed by General Office Staff and then kept with the valuables

Blue Copy

To remain in the Valuables Book

Out of Office Hours

If it is decided by the patient that their valuables should be kept by the hospital, then place them in the nurses safe. These are then taken by the senior nurse in charge to the main safe, the next working day

Following the procedure as previously detailed for recording the valuables in the Valuables Book see section 5. It is essential that the senior nurse in charge follows the same procedure and MUST sign the green copy of the Patient’s Valuables Book.

Out of office hours there is no provision for patient’s valuables to be returned. Therefore, it is important to ensure that if the patient is to be discharged or if the patient needs access to part of their money the valuables are retrieved when bereavement officer on duty.

If the patient is discharged without having retrieved their valuables, the money will be banked and a cheque request sent to Finance. With regards to the other valuables the next of kin will be contacted to arrange collection

8. Retrieval of Valuables

Valuables in the ward safe can be returned to a patient on discharge.

Upon the request from the patient, and on production of the white copy of the patient’s valuables book, valuables are discharged by the senior nurse in charge or delegated individual. The patient is required to sign the reverse of the green copy of the patient’s valuables book.

9. Deceased Patients Valuables

During Office Hours

If a patient passes away during office hours, the bagged clothing and valuables are taken to the Nurses Office, ensuring that the White, Pink and Green copies are attached to the valuables and valuables.

The senior nurse in charge / bereavement officer will then wait for the relatives to collect the valuables and valuables, ensuring that the:

White copy is given to the relatives Pink copy is kept with the notes by scanning these into the S1 record. Green copy is signed by the relatives for any valuables

Out of Office Hours

If a patient passes away outside of office hours, the valuables are given to the senior nurse in charge, ensuring that they are in a patient’s valuables envelope, clearly marked with name, date of death, ward, patients’ record number etc. and placed in the Nurses / Bereavement office.

The deceased patient’s clothing is placed in the Nurses / Bereavement office, ensuring that the clothing is bagged and clearly marked with the patient’s details and will be dealt with the next working day by the Bereavement officer.

If the deceased patient has more than £50 in cash, the relatives are not allowed to take it. They can take the jewellery, having signed an indemnity form, the money will be banked by Finance and the receipt given to the relatives. A cheque is then issued by Finance made out to the deceased’s next-of-kin/executor.

10.Reconciliation of Safe Content

During office hours the main safe is reconciled daily. All logged items are accounted for and logged along with the time and date of the reconciliation.

There are two keys to the safe, one master key (held by the senior nurse in charge / bereavement officer) and one key handed to a designated deputy. Both keys must remain on site and with a responsible duty officer. Whilst only one of these keys will be required to open the safe a minimum of two persons must be present in the area whilst the safe is in the unlocked position and remain in the area until the safe contents are

secured. At Braintree Community Hospital there is only one key and it is stored in the coded key safe.

The safe is to be kept locked at all other times (excluding when a deposit is made and when a patient requests their belongings).

Ward safes are also checked daily by the senior nurse in charge / bereavement officer and these checks must be documented to provide a clear audit trail.

11.Loss of Patients Valuables

In the event that valuables is thought to be lost or thought to be stolen, it is the responsibility of the senior nurse in charge to initiate a full investigation in to the alleged loss and where possible arrange for the safe return of valuables.

In the event that valuables cannot be found the senior nurse in charge will liaise with the Accredited Security Management Specialist for the organisation.

A Datix incident form must be completed for all reported lost or stolen items.

12.Communication and Implementation

This policy will available on the organisation’s intranet and will be promoted via the staff newsletter and sent via email to all senior nurses in charge for dissemination to their staff.

13.Review

This policy will be reviewed in two years or earlier in response to results from monitoring compliance, changes in practice or other local or national initiatives.

Appendix 1: Disclaimer Form

DISCLAIMER FORM FOR PATIENTS VALUABLES AND CASH

I have, by my own choice, decided to retain the following valuables and cash in my possession:

The organisation has offered to place these items into safe keeping and issue me with a receipt. I do not wish to accept this offer and I fully accept the responsibility for their future security.

Signed:…………………………………………………………………………………………

Name:…………………………………………………………………………………………

Date:……………………………………………………………………………………………

Witnessed by:

Name:………………………………………………………………………………………

Signature:………………………………………………………………………………………

Ward:……………………………………………………………………………………………

Date:………………………………………………………………………

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’

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

HSPOL20 Managing Patient Valuables

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

This policy sets out the process for dealing with patient’s valuables whilst in one of the three community hospitals managed by Provide

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”?

Neutral

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 address particular 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