Lockdown - Black Country Partnership
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Lockdown
Target Audience
Who Should Read This Policy
All Trust Staff
Version 2.0 May 2019Lockdown Policy Ref. Contents Page 1.0 Introduction 4 2.0 Purpose 4 3.0 Objectives 4 4.0 Procedures 5 5.0 Procedures Connected to this Policy 11 6.0 Links to Relevant Legislation 11 6.1 Links to Relevant National Standards 12 6.2 Links to other key policy/s 12 6.3 References 13 7.0 Roles and Responsibilities for this Policy 14 8.0 Training 15 9.0 Equality Impact Assessment 15 10.0 Data Protection and Freedom of Information 15 11.0 Monitoring this policy is working in practice 16 Appendices 1.0 NHS Lockdown Vulnerability Assessment 17 2.0 Lockdown Action Cards 19 3.0 Site Specific Aide Memoirs on Lockdown 22 4.0 Lockdown Incident Log 27 Version 2.0 May 2019 2
Lockdown Policy Explanation of terms used in this policy Lockdown – Process of controlling the movement and access – both entry and exit – of people (NHS staff, patients and visitors) around a Trust site or other specific Trust buildings or area in response to an identified risk, threat or hazard that might impact upon the security and/or safety of patients, staff and assets or, indeed, the capacity of that facility/service to continue to operate Total Lockdown - All perimeter doors/gates are secured and no one is allowed to enter or exit the facility. Security personnel or other designated members of staff will be assigned to key entrances and exits Partial Lockdown - Only a specific part of a facility/building will be locked down. Everyone will be directed towards specific pre-designated entrances and exits. Security personnel or other designated members of staff will control and screen who is allowed to enter or exit these areas as defined in this guidance Controlled Lockdown: Exit Only - Security personnel or other designated members of staff will control and screen who is allowed to exit the lockdown area as defined in this guidance Controlled Lockdown: Entry Only - Security personnel or other designated members of staff will control and screen who is allowed to enter the lockdown area as defined in this guidance Controlled Lockdown: Entry and Exit - Security personnel or other designated members of staff will control and screen who is allowed to enter or exit these areas Threat - Malicious event instigated by an individual or group which has the potential to cause loss or damage to an asset. This could include technological accidents or terrorists attack Hazard - Source of potential danger or adverse conditions. This could include natural hazards (flooding, storm, tornado, and hurricane) Version 2.0 May 2019 3
Lockdown Policy
1.0 Introduction
A lockdown is achieved through a combination of physical security measures and
either the deployment of staff or security personnel. This policy recognises aspects of
the law in respect of the Civil Contingencies Act 2004, Public Health (Control of
Diseases) Act 1984 and the Human Rights Act 1998.
In the absence of the Police who are able to enforce a containment cordon it will be
only lawful for an NHS trust to prevent the exit of a significant number of people from
its premises by utilising specific legislative provision (e.g. emergency regulations
under the Civil Contingencies Act and/or the Public Health (Control of Infectious
Disease) Act 1984) which provides for the protection of the public from notifiable
diseases.
Even when these specific regulations are used specific tenets of the Human Rights
Act 1998 must be considered – e.g. a person’s right to liberty (Article 5) and an
individual’s right to a family (Article 12). Without these regulations exit could only be
prevented in relation to specific individuals in certain circumstances which are likely
to be limited to the following situations:
The individual is committing an offence or causing injury or damage to
property which may lead to him or her being arrested
They are detained under the Mental Health Act or otherwise lawfully detained
While staff can give direction within their premises it is unlawful to forcibly prevent
exit from NHS premises unless it is for the reasons stated above. Without these
justifications NHS staff could be open to legal action under criminal and/or civil law if
they prevent a person from leaving.
2.0 Purpose
The purpose of this policy is to prepare and plan for serious security incidents or
unexpected situations that may require a full or partial lockdown of Trust managed
premises. Any lockdown will need to be managed and controlled in order to maintain
the health and safety of all occupants, as well as the security of Trust assets. This
policy applies to all staff, patients, visitors and contractors who are present on any
Trust sites affected by the instigation of a Lockdown.
3.0 Objectives
The objective of this policy is to provide guidance and instruction when to and how to
totally or partially lockdown and secure any Trust building or department in the event
of an emergency situation, threat or hazardous scenario such as a major accident,
terrorist activity, pandemic flu outbreak, other infection risk, serious crime scene or a
mass public disorder event such as a riot.
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4.0 Procedures
The flow chart shows the immediate actions to be taken for initiating Lockdown
EMERGENCY SITUATION
I.e. civil unrest, terrorist incident, fire
Emergency Services Informed
DYNAMIC RISK ASSESSMENT – is Lockdown Required?
Contact
1. On-Call Director
2. Service Director
3. Chief Executive
The authority required depends on the urgency of the situation. The risk
assessment may be in conjunction with the Emergency Services
YES DECISION MADE NO
Follow your local locking up Lockdown not
(should this be lockdown) necessary at
procedures present but
situation will be
Commence Lockdown process and monitored and
establish safe and controlled zones reviewed
as directed by the emergency
services or incident lead (local
manager)
All on site staff not engaged in
immediate patient care report to
the Trust incident lead for direction Hospital sites due to
many access points can
be supported by
Contracted Security
Follow the Major Incident Services. Contact
Emergency Plan and Business Estates and Facilities
Continuity Arrangements Numbers of guards will
depend on number of
access points
Where appropriate – utilise
Information/Action Cards
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4.1 Potential Threats
A wide range of threats and hazards should be considered during the development of
lockdown plans. Below are some examples of potential threats and hazards to be
considered.
Malicious threats Malicious threats Malicious threats Potential
to persons to buildings and to property lockdown hazards
estates
Violence against Vandalism Theft of service Flooding
staff, patients and assets and
visitors personal
equipment
Abuse against Unlawful entry Contamination of Fire
staff, patients and clinical supplies
visitors and products
Contamination
Terrorism Terrorism Terrorism (CBRN incidents)
4.2 Levels of Lockdown
Lockdown risk profiles will be produced for each site highlighted as RED at
Appendix 1 to identify what lockdown measures, if any, are required in response to
the identified threat or potential threat to each Trust site.
Total Lockdown All perimeter doors/gates are secured and no one is allowed to
enter or exit the facility. Security personnel or other designated
members of staff will be assigned to key entrances and exits
Partial Only a specific part of a facility/building will be locked down.
Lockdown Everyone will be directed towards specific pre-designated
entrances and exits. Security personnel or other designated
members of staff will control and screen who is allowed to enter
or exit these areas as defined in this guidance
Controlled Security personnel or other designated members of staff will
Lockdown: Exit control and screen who is allowed to exit the lockdown area as
Only defined in this guidance
Controlled Security personnel or other designated members of staff will
Lockdown: Entry control and screen who is allowed to enter the lockdown area as
Only defined in this guidance
Controlled Security personnel or other designated members of staff will
Lockdown: Entry control and screen who is allowed to enter or exit these areas
& Exit
4.3 Activating a Lockdown
A decision to initiate a lockdown should be guided by the following factors:
The potential for harm to people or property
Whether it is possible to isolate or neutralise the source of the threat or hazard
How far people or property are from the source of the threat or hazard
Possibility of cross contamination
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The scenario’s that may warrant the activation of a lockdown and may also be
categorised as a Major Incident are:
Fire
Flooding of premises
Acts of Terrorism
Hostage Situations
Chemical, Biological contamination (including self-presenting individuals and
“worried well” inappropriately attending Trust Sites)
Structure Collapse
Escape/missing Patient from Low Secure UnitLoss or theft of keys from Low
Secure Unit
Mass public disorder (Riot)
Once a lockdown has been initiated, its time and duration will depend on the
individual circumstances. Staff will take every effort to minimise the duration as much
as possible.
Depending on the scenario, if a full lockdown is needed at “hospital sites” the On-Call
Director or their representatives (if warranted such measures) should contact the
emergency services immediately for their assistance and request through Estates
and Facilities the provision of contracted security guards to assist in the manning of
entrances and access/exit points.
The Police (and Fire Service) may also be able to assist in the management of on -
site traffic, crowd control and any evacuation.
The initiation of a full lock down should also be where possible, communicated to
Trust staff on Trust coms. If the lock down has been initiated out of hours or on the
weekend, Penn reception should be informed of the lock down (providing that Penn
reception is not on lock down).
If only a partial or progressive lockdown is needed, the senior manager with staff
support should make every effort to manage/contain the situation with a view to
contacting the emergency and contracted security services if the circumstances
begin to escalate.
As soon as a lockdown has been called, staff should report to an agreed location. At
this point, they will need to identify key resources, all of which should be maintained
at a central location:
Map – of the premises, contained in the Fire Evacuation Procedures
Keys – to secure doors
Two-way radios – where available as part of the Fire Evacuation Procedures
Tabards/high visibility vest – to identify key staff
Signage / barriers – where available to highlight no access routes on site
The most senior member of staff should keep an accurate record of events from
the point that the lockdown is initiated until stand own is given, see page 28 for
basic lockdown occurrence log
4.4 Staff Deployment
The Trust does not employ full time security personnel. Arrangements for securing an
area will therefore depend on the availability of staff present in the building at the
time.
Version 2.0 May 2019 7Lockdown Policy Once members of staff have been issued with the items above they will need to go as quickly as possible to their allocated areas. Action must be taken quickly to secure the building. Any access controls should be utilised to speed up the process. A manual lockdown (using keys) should be undertaken as quickly and safely as possible. To speed up a manual lockdown, careful consideration needs to be given to the order in which doors and windows will be locked. Senior staff should decide this based on the high risk areas within their premises, their use and accessibility to the public. Ward staff will be responsible for controlling the movement of patients/visitors within their ward areas. Where possible, contracted security personnel may be positioned at the main entrances/fire exits of Trust hospital sites to explain the situation to people and request their co-operation. It is important that some staff are positioned by the main exit doors as fire legislation may prevent these from being locked. Staff should remain calm and professional during the deployment in order to keep visitors and patients calm. Once members of staff are in control of their areas they should communicate this to the Senior Manager. Communication links should be maintained at all times so that staff can be updated on the progress of the lockdown. 4.5 Controlling Access Egress NHS Trusts have the right to refuse access. If someone enters the premises having been advised not to, or is already in the premises but refuses to leave; they may be considered a trespasser and reasonable force may be used to prevent access or remove them. If an individual enters a locked down premises or refuses to leave, they could be prosecuted. NB: patients attending a locked down premises may be subject to the doctrine of ‘best interest’ and treatment elsewhere may be considered most appropriate thus not infringing on their ‘right to treatment’ under the Human Rights Act. It is important to remember that staff can only appeal to people to stay inside a locked down area. If people still choose to leave, a safe route must be available for them to do so. The exit of individuals can only be prevented if relevant sections of the Mental Health Act apply, or if by leaving, the person is committing a criminal offence, or causing injury to property, thus leading to arrest. 4.6 Declaring a Stand down Once the decision has been given to stand down, staff should open key doors first. Any signage or barriers should be removed in order of risk/priority to allow access again. Staff should reassure patients and visitors during the stand down in order to keep them calm. Senior staff or the On-Call Manager will need to contact the Communications Team to inform them of the lockdown outcome and any resolved/unresolved situations. Version 2.0 May 2019 8
Lockdown Policy
4.7 Vulnerability Assessment
A joint assessment exercise has been carried out by the Health and Safety Manager
and the Local Security Management Specialist (LSMS). A collaborative opinion on
each Trust building has been incorporated into a Trust wide vulnerability assessment
taking into account the guidelines issued by the NHS Security Management Service
on the threat categories to be considered (See Appendix 1)
The vulnerabilities of a particular Trust building/service can be reassessed at any
time in response to a change of use, change of location etc.
Each Trust building has received a vulnerability score. Buildings with a score of
8 or above are rated Red and have been assigned specific Lockdown
procedures in addition to this policy (See Appendix 3). Scores of 8 or more are
given to Trust hospital sites due to their size, the need to secure perimeters and
possible high numbers of visitors and access / exit doors. Hospital staff must
follow Action Card 1 (See Appendix 2)
Buildings with a score of 6 - 7 are Moderate risk due to being a secure area with
controlled access. During lockdown these buildings must follow Action Card 2
(See Appendix 2)
All community sites will comply with Action Card 3 (See Appendix 2)
Buildings with a score of 5 or less will not be subject to Lockdown as they are
offices and non patient locations however staff must be aware of the lockdown
procedures and should also follow Action Card 3 (See Appendix 2)
Full security assessments of buildings and assets for each site graded red will be
completed as part of full risk profile (See Appendix 1).
4.8 Locking Down Main Hospital Sites
The success of a lockdown may depend upon the time of day that it is initiated. A
lockdown called at 02.00am on a Sunday morning may be harder to achieve because
there may be fewer staff on duty. Conversely, no visitors are likely to be on-site at
this time which may make a lockdown easier to maintain. As part of emergency
planning lockdown scenarios should be practiced when the Trust is at its most
vulnerable in terms of staffing etc.
All wards on Trust hospital sites are locked by way of design therefore the focus
should be on securing final exit / entry routes including preventing vehicle access on
to the site.
4.9 Lockdown of Trust Owned/Leased Community Buildings
Lockdown procedures of Trust owned community sites will prove less complicated
than that of the hospital sites and may require a more simplistic approach such as
denying access and egress by closing all doors and providing close management of
visitors until the stand-down has been declared.
A serious incident within the community such as an act of terrorism or a major fire
may result in the call for one or more Trust Community Service to initiate its lockdown
procedures for the safety of staff and visitors.
4.10 Staffing and Resources
The numbers of staff needed during a lockdown will depend on the nature and size of
the incident. Lockdowns can be small, medium, or large-scale depending on the type
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of incident. The number of staff needed will be dependent on a number of variables
relating to the size of the site, number of buildings, access and egress points, and
existing security arrangements. Consideration should be given to calling in extra staff
to help with the lock down or redeploying staff from other areas if safe to do so.
Trust staff will:
a) Participate as required in the event of the implementation of a lockdown.
b) Undertake relevant activities to support lockdown procedures.
c) Report to their manager, situations where exposure to any security or infection hazard /
threat may give cause for concern so that investigation and appropriate action can be
undertaken.
d) Keep talking to a minimum to receive further instructions.
e) Follow the prompts from team managers.
f) Close windows and doors where it is safe to do so.
g) Be prepared to respond quickly to any emergency services or other Responder(s)
Instructions.
h) Take reasonable care of their own safety and security as well as the safety and security of
others
4.11 Lockdown of Shared (Non-Trust Owned) Community Premises
Where staff are based in the community providing healthcare service within the
premises of other healthcare providers, all BCPFT staff shall:
Adhere to the local policies and procedures of other employers/building owners;
Cooperate with the emergency arrangements of other employers
Inform BCPFT of disruptions affecting service delivery and maintain hourly
contact with the Trust.
Contracted Security Staff are NOT available for sites not owned by BCPFT
4.12 Who Will Notify the Trust to Lockdown its Premises?
Notification or decision to lockdown a premise may be either internal or external e.g.
from local managers or the emergency services such as the Police or directly from
NHS England. The emergency services or local government may make public
announcements via various media platforms.
4.13 How Will we Receive Notification to Lockdown Premises?
Notification to lockdown a Trust premise may come via direct telephone call to the
Chief Executive or via fax or text message via a pager to the On-Call Director.
On such notification staff should be prepared to brief visitors, members of the public
and other building users of the threat. Other healthcare professionals not employed
by the Trust may be required to provide assistance as necessary.
4.14 Who has Authority to Lockdown Trust Premises?
The Chief Executive or their nominated Director after first obtaining advice from the
Police or those in command are the only designated person with authority to close a
Trust owned service within the community. In certain situations it may be necessary
for the most senior member of staff on site to initiate a lockdown in response to an
internal or external Major Incident. The Chief Executive or nominated Director should
be contacted as soon as practicable to provide an update and rationale behind the
lockdown.
4.15 What Should I do if Members of the Public Want to Leave a Building that is
Under Lockdown?
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If a lockdown has been declared, depending on the scenario and location of the
hazard and threat it may be acceptable to allow visitors and members of the public to
leave the building but only if it safe to do so without endangering life allowing staff to
safely close the service. It is important to remember that staff can only appeal to
people to stay inside a locked down area. If people still choose to leave, a safe route
must be available for them to do so. The exit of individuals can only be prevented if
relevant sections of the Mental Health Act apply, or if by leaving, the person is
committing a criminal offence, or causing injury to property, thus leading to arrest.
4.16 Who is Authorised to Declare a Stand-Down and Resume Services?
Only the Chief Executive or the On-Call Director (on the advice of the emergency
services) are authorised to instigate the stand-down which will be communicated
directly to Executive Directors in charge of services who will verify the instruction
before taking action and resuming normal service.
5.0 Procedures Connected to this Policy
There are no procedures connected to this policy.
6.0 Links to Relevant Legislation
Health and Safety at work etc. Act 1974
This Act is the major piece of health and safety legislation in Great Britain. The Act
introduced a comprehensive and integrated system to deal with workplace health and
safety and the protection of the public from work activities.
The Act places general duties on employers, employees, self-employed,
manufacturers and importers of work equipment and materials. Responsibilities are
placed to produce solutions to health and safety problems, which are subject to the
test of reasonable practicability.
Various regulations are made under the Act, which have the same scope, many of
these evolving from European Directives, which enables the potential to achieve
clear and uniform standards.
Civil Contingencies Act 2004
The Civil Contingencies Act delivers a single framework for civil protection in the UK.
The Act is separated into 2 substantive parts: local arrangements for civil protection
(Part 1); and emergency powers (Part 2).
Part 1 of the Act and supporting Regulations and statutory guidance ‘Emergency
preparedness’ establish a clear set of roles and responsibilities for those involved in
emergency preparation and response at the local level. The Act divides local
responders into 2 categories, imposing a different set of duties on each.
Those in Category 1 are organisations at the core of the response to most
emergencies (the emergency services, local authorities, NHS bodies). Category 1
responders are subject to the full set of civil protection duties. They will be required
to:
Assess the risk of emergencies occurring and use this to inform contingency
planning
Put in place emergency plans
Put in place business continuity management arrangements
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Put in place arrangements to make information available to the public about civil
protection matters and maintain arrangements to warn, inform and advise the
public in the event of an emergency
Share information with other local responders to enhance co-ordination
Co-operate with other local responders to enhance co-ordination and efficiency
Provide advice and assistance to businesses and voluntary organisations about
business continuity management (local authorities only)
6.1 Links to Relevant National Standards
CQC Regulation 15: Premises and Equipment
The intention of this regulation is to make sure that the premises where care and
treatment are delivered are clean, suitable for the intended purpose, maintained and
where required, appropriately located, and that the equipment that is used to deliver
care and treatment is clean, suitable for the intended purpose, maintained, stored
securely and used properly. Providers retain legal responsibility under these
regulations when they delegate responsibility through contracts or legal agreements
to a third party, independent suppliers, professionals, supply chains or contractors.
They must therefore make sure that they meet the regulation, as responsibility for
any shortfall rests with the provider.
Where the person using the service owns the equipment needed to deliver their care
and treatment, or the provider does not provide it, the provider should make every
effort to make sure that it is clean, safe and suitable for use.
6.2 Links to other key policy/s
Business Continuity Management Policy
Although the Trust is classed as a ‘category 1’ responder under the Civil
Contingencies Act 2004, this is by definition due to its attainment of Foundation Trust
status. Thus, within major incident planning and response arrangements the Trust is
not expected to play a major role within a traditional ‘major incident’ scenario. The
focus for the Trust should therefore be on developing and embedding appropriate
business continuity arrangements to ensure it can effectively meet the challenges of
incidents that can disrupt the continuity of its critical and essential services under the
NHS England Emergency Preparedness Framework 2013.
The aim of this policy is to provide an effective business continuity framework which
will allow the Trust to meet its regulatory obligations.
Risk Management Policy
The purpose of the Risk Management Policy is to provide an effective framework
through which the Trust can safely and effectively manage risks.
This policy does not cover individual patient clinical risk assessments which may be
identified as part of a patients care plan. These individual clinical risk assessments
for example, falls risk assessments, suicide risk assessments etc. will be conducted
in line with the relevant clinical policy and process for the risk identified.
Security Management Policy
The purpose of this policy is to detail the Trust’s strategy/legislative compliance in
maintaining a safe working environment, and safe and secure healthcare premises.
Version 2.0 May 2019 12Lockdown Policy 6.3 References Mental Health Act 1983 (as revised 2007) Mental Health Act Code of Practice 1999 (as revised 2008) European Convention on Human Rights Version 2.0 May 2019 13
Lockdown Policy
7.0 Roles and Responsibilities for this Policy
Title Role Responsibilities
All staff Adherence - Report to their manager situations where exposure to any security hazard/threat may give cause for concern, so that
investigation and appropriate action can be undertaken
- Ensure their actions do not endanger the safety or security of others
- Ensure they are aware of local emergency procedures
- Follow directions from the incident lead in the event of a Lockdown or major incident
Ward/ Department Operational - Ensure that this policy is implemented in their areas
Manager (Local - Seek the approval from the On-Call Director/Senior Manager of any incident they believe may justify a Lockdown. However,
Incident Managers) circumstances may be such that a dynamic risk assessment of the situation calls for an immediate Lockdown, in which case
the Manager has the delegated authority to do so. The On-Call Director/Senior Manager must be immediately informed
On-Call Director (24hr Implementation - Call a Lockdown when necessary (there may be occasions when a manager present at an incident location calls for a
responder) Lockdown following a dynamic assessment of the situation. In such an event, the On-Call Director/ Senior Manager, must
be notified immediately after the Lockdown has been called)
- Ensure that the Chief Executive and the Communications Team are informed of any lockdown situation. This will enable a
major incident to be declared, and ensure that appropriate support and assistance is provided to the affected site
Local security Implementation - Ensure that all areas identified as RED in the building vulnerability assessment have in place detailed site specific Lockdown
Management Specialist arrangements
(LSMS) - Ensure that such arrangements are tested annually
Executive Management Executive Leads - Ensure that the security of staff, patients and visitors is given a high priority in the overall management strategy of the
Team Trust
- Ensure that adequate resources are made available to ensure compliance with statutory regulations and NHS guidelines
Chief Executive and/or Assurance - Person in control of premises
Director of Operations - Default authority to call a Lockdown situation
Estates Department Buildings - Provide technical advice on structures and systems to relevant managers, Directors and Trust on call commanders, where
appropriate
- Conduct a building structure and systems assessment following a lockdown, identifying faults or damage in need of repair
or replacement
- Conduct a building structure and systems assessment following a lockdown and identifying upgrades to make a lockdown
more effective
- Source and provide contracted Security staff with enhanced DBS clearance
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8.0 Training
What aspect(s) Is this training covered in the
Which staff groups Trust’s Mandatory and Risk How often will Who will ensure and
of this policy will If no, how will the Who will deliver the
require this Management Training Needs staff require monitor that staff have
require staff training be delivered? training?
training? Analysis document? training this training?
training?
Responding to Frontline staff No, staff will receive specific Internally - Table top Emergency planning Annually Health and Safety
emergencies training in relation to this policy exercise to test planning Officer Committee/ Emergency
where it is identified in their arrangements Planning Group
individual training needs
analysis as part of their
development for their particular
role and responsibilities
9.0 Equality Impact Assessment
Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff
reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact
Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print,
Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email bcpft.equalityimpactassessment@nhs.net
10.0 Data Protection and Freedom of Information
Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It
sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law
applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data
Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4%
of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data
processing activities where there has been a serious breach of the Act and there remains a risk to the data.
The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information
legislation is that people have a right to know about the activities of public authorities; unless there is a good reason for them not to. The Freedom of
Information Act applies to corporate data and personal data generally cannot be released under this Act.
All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service
users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently
employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to
ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies.
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The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following
formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team.
11.0 Monitoring this policy is working in practice
What key elements will be Where How will they be Who will Group/Committee Group/Committee Evidence
How
monitored? described in monitored? undertake this that will receive and to ensure actions this has
Frequently?
(measurable policy objectives) policy? (method + sample size) monitoring? review results are completed happened
Table top lockdown exercises 4.0 Process Lockdown Action Cards/ Emergency Annually Health and Safety Health and Safety Minutes of
should be carried out in Procedure Checklists planning Officer Committee/ Committee meetings
accordance with local Emergency Planning
procedures Group
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Appendix 1
NHS Lockdown Vulnerability Assessment
(High = 3 – Med = 2 Low = 1)
Asse Name / Service Function Malicious Malicious Malicious Natural Score Lockdown profile
t threats to threats to threats to hazards/ and procedure
people buildings property other required
and assets hazards
estates
1 Edward St Hospital, Reception, Inpatient older adult hospital 2 2 2 2 8 See Action Card 1
TARU, outpatients, lighthouse
2 Penn Hospital, Reception, Secure inpatient young adult 2 2 2 2 8 See Action Card 1
Willows, Groves ward
3 Meadow Ward Secure older adult ward 1 1 1 2 6 See Action Card 2
4 Brook Ward Secure young adult ward 2 1 1 2 6 See Action Card 2
5 Dale Ward Secure young adult ward 2 1 1 2 6 See Action Card 2
6 Jasmine Staff offices 0 1 1 2 4 See Action Card 3
7 Juniper Staff offices 0 1 1 2 4 See Action Card 3
10 Macarthur Unit Secure forensic inpatient unit 2 2 2 2 8 See Action Card 1
11 Gerry Simon Clinic Secure forensic inpatient unit 2 2 2 2 8 See Action Card 1
12 Penrose House Secure inpatient unit 2 2 1 2 8 See Action Card 1
Tredgold House Offices / Catering 0 1 1 2 4 See Action Card 3
13 Pond lane Offices / Outpatients 1 1 1 2 5 See Action Card 3
14 Ridge Hill Inpatient Unoccupied
15 Ridge Hill Admin Block Offices / Outpatients 2 2 1 2 7 See Action Card 2
16 Charlemont Ward Secure young adult ward 2 2 1 2 7 See Action Card 2
17 Friar Ward Secure young adult ward 2 2 1 2 7 See Action Card 2
18 Abbey Ward Secure young adult ward 2 2 1 2 7 See Action Card 2
19 Larches Secure young adult ward 2 2 1 2 7 See Action Card 2
20 Hallam Street Resources Centre Offices / Outpatients 2 2 2 2 8 See Action Card 1
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Asset Name / Service Function Malicious Malicious Malicious Natural Score Lockdown profile
threats to threats to threats to hazards and procedure
people buildings property required
and Assets
estates
21 Sunflower Centre Offices / Outpatients 1 1 1 2 5 See Action Card 3
21 Steps to Health Offices / Outpatients 1 1 1 2 5 See Action Card 3
22 Delta House Offices 1 1 1 2 5 See Action Card 3
23 Quayside Offices / Outpatients 1 2 1 2 6 See Action Card 2
24 Valley Park Offices, children’s education room 1 1 1 2 5 See Action Card 3
25 Daisy Bank Unoccupied
26 Orchard Hills Offices 1 1 1 2 5 See Action Card 3
27 Brooklands Parade Offices / Outpatients 1 1 1 2 5 See Action Card 3
28 Cleveland House Offices 1 1 1 2 5 See Action Card 3
29 Leasowes House Offices 1 1 1 2 5 See Action Card 3
30 St Michaels Court Offices / Outpatients 1 1 1 2 5 See Action Card 3
31 323 High Street Offices / Outpatients 1 1 1 1 4 See Action Card 3
32 Lodge Road Offices / Outpatients 1 2 1 2 6 See Action Card 2
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Appendix 2
Lockdown Action Cards
Lockdown - Action Card 1
Hospital Sites
Communicate Lockdown Status (Control)
Lockdown instruction received, authorised by (identify Authoriser). Confirm the
reasons why and the level of risk
Follow the Trusts Major Incident Response Plan – Start incident log/book
Communicate instructions to all staff to “Lockdown”
Ensure “this is not a drill / practice” is communicated
Implement Assigned Responsibilities (Control)
If required, call 999 and request assistance as needed
If required, call Estates and Facilities and request contracted security service
Out of Hours, notify the Trust Duty On-Call Director of ward /building status
During normal working hours notify the Trust Duty On-Call Director, Emergency
Planning Officer, LSMS of Ward status
Lock all exit / entry (external windows and doors) points leading into the building
and to the wards
Assign duties to staff the main access point for emergency access via identity
card only (excluding Chemical, biological, Radioactive or Nuclear (CBRN)
incident)
Assign duties of controlling exit/entry from the building where service users and
visitors are present. (Contracted security service can take over these duties)
Deploy staff at vehicle entry points (cordon off access with barriers or mine
tape). Security services on arrival can take over this duty
Provide safe area in building for visitors and service users (this could be the
canteen, reception area, waiting lounges or a large meeting room close to a
final exit door). Allocate staff to stay with visitors at all times until stand down
declared
If visitors wish to leave assess the situation and provide safe exit route
Notify and maintain regular contact with service Director / senior manager of
ongoing status
Maintain a log of events, actions and instructions
Await further instructions
Change of Shift
If possible make contact with oncoming shift as they may be denied access
Make arrangements for staff staying on shift longer than anticipated
Maintain patient comfort
Recovery
Resume normal operations ASAP, remove barriers, un-lock doors
Provide advice and support to staff, visitors and service users
Ensure any after care where required and debriefings are carried out
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Lockdown - Action Card 2
Ward Managers
Communicate Lockdown Status (Control)
Lockdown instruction received, authorised by (identify Authoriser), and confirm
the reason why and the risk
Follow the Trusts Major Incident Response Plan – Start incident log/book
Communicate instructions to all ward staff to “Lockdown”
Ensure “this is not a drill / practice” is communicated
Implement Assigned Responsibilities (Control)
If required, call 999 and request assistance as needed
Out of Hours, notify the Trust Duty On-Call Director of ward /building status
During normal working hours notify the Trust Duty On-Call Director, Emergency
Planning Officer, LSMS of Ward status
Lock all exit / entry (external windows and doors) points leading to the
ward/area
Assign duties of staffing main access point for emergency access via identity
card only (excluding Chemical, biological, Radioactive or Nuclear (CBRN)
incident)
Assign duties of controlling exit from the building where service users and
visitors are present
If safe to do so maintain visitors on ward until stand down
If visitors wish to leave access the situation and provide safe exit route from
ward to a final exit point
Notify and maintain regular contact with service Director / senior manager of
ongoing status
Maintain a log of events, actions and instructions
Await further instructions
Change of Shift
If possible make contact with oncoming shift as they may be denied access
Make arrangements for staff staying on shift longer than anticipated
Maintain patient comfort
RECOVERY
Resume normal operations ASAP
Provide advice and support to staff
Ensure any after care where required and debriefings are carried out
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Lockdown - Action Card 3
Community Sites
Communicate Lockdown Status (Control)
Lockdown instruction received, authorised by (identify Authoriser), and confirm
the reason why and the risk
Follow the Trusts Major Incident Response Plan – Start incident log/book
Communicate instructions to all staff to “Lockdown”
Ensure “this is not a drill / practice” is communicated
Comply with other employers Lockdown emergency procedures
Implement Assigned Responsibilities (Control)
During normal working hours notify the Trust Duty On-Call Director, Emergency
Planning Officer, LSMS of building status
Lock all exit / entry (external windows and doors) points leading into building
Assign duties to man the main access point for emergency access via identity
card only (excluding Chemical, biological, Radioactive or Nuclear (CBRN)
incident)
Assign duties of controlling exit/entry doors from the building where service
users and visitors are present
Assign duties to prevent vehicle access on to car parks
If safe to do so maintain visitors in the building until stand down
Locate visitors in one area / room and provide close supervision
Brief visitors on incident and inform to stay for own safety
If visitors wish to leave assess the situation and provide safe exit from the
building
Notify and maintain regular contact with service Director / senior manager of
ongoing status
Maintain a log of events, actions and instructions
Await further instructions
Recovery
Resume normal operations ASAP
Provide advice and support to staff
Ensure any after care where required and debriefings are carried out
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Appendix 3
Site Specific Aide Memoirs on Lockdown
EDWARD STREET HOSPITAL
Physical Security
Immediately secure main front entrance door and
deactivate inner automatic opening door
Immediately secure door leading from café to outer area
Immediately secure side door adjacent to lifts
Immediately ensure that any other fire exit doors are
secure
Ensure that any ground floor (or first floor windows that are
accessible) are secured
Maintain a staff presence at all exit doors to ensure the
secure cordon is not compromised by unauthorised egress
from site
Inform Lodge Road and Community Team Base
Total Lockdown All perimeter doors/gates are secured and no one is allowed to enter
or exit the facility. Security personnel or other designated members of
staff will be assigned to key entrances and exits
Partial Lockdown Only a specific part of a facility/building will be locked down. Everyone
will be directed towards specific pre-designated entrances and exits.
Security personnel or other designated members of staff will control
and screen who is allowed to enter or exit these areas as defined in
this guidance
Controlled Security personnel or other designated members of staff will control
Lockdown: Exit and screen who is allowed to exit the lockdown area as defined in this
Only guidance
Controlled Security personnel or other designated members of staff will
Lockdown: Entry control and screen who is allowed to enter the lockdown area as
Only defined in this guidance
Controlled Security personnel or other designated members of staff will control
Lockdown: Entry and screen who is allowed to enter or exit these areas
& Exit
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GENERAL LOCKDOWN PROCESS
Physical Security
Immediately secure main entrance door and deactivate
any automatic opening door mechanisms
Immediately secure any other doors affording access to
the building
Immediately ensure that any other fire exit doors are
secure
Ensure that any ground floor (or first floor windows that are
accessible) are secured
Maintain a staff presence at all exit doors to ensure the
secure cordon is not compromised by unauthorised egress
from site
Inform adjoining NHS premises/services of the incident
Total Lockdown All perimeter doors/gates are secured and no one is allowed to enter
or exit the facility. Security personnel or other designated members of
staff will be assigned to key entrances and exits
Partial Lockdown Only a specific part of a facility/building will be locked down. Everyone
will be directed towards specific pre-designated entrances and exits.
Security personnel or other designated members of staff will control
and screen who is allowed to enter or exit these areas as defined in
this guidance
Controlled Security personnel or other designated members of staff will control
Lockdown: Exit and screen who is allowed to exit the lockdown area as defined in this
Only guidance
Controlled Security personnel or other designated members of staff will
Lockdown: Entry control and screen who is allowed to enter the lockdown area as
Only defined in this guidance
Controlled Security personnel or other designated members of staff will control
Lockdown: Entry and screen who is allowed to enter or exit these areas
& Exit
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HALLAM STREET HOSPITAL
Physical Security
Immediately secure main front entrance doors and deactivate
automatic opening
Immediately secure rear door leading from O/T corridor to outer
area/carpark
Immediately secure side door from restricted staff area to carpark
Immediately ensure that any other fire exit doors are secure
Ensure that any ground floor (or first floor windows that are
accessible) are secured
Maintain a staff presence at all exit doors to ensure the secure
cordon is not compromised by unauthorised egress from site
Inform Catering so that they can implement the above
Inform wards so that they can implement the above including the
securing of garden/courtyard doors
Total Lockdown All perimeter doors/gates are secured and no one is allowed to enter
or exit the facility. Security personnel or other designated members of
staff will be assigned to key entrances and exits
Partial Lockdown Only a specific part of a facility/building will be locked down. Everyone
will be directed towards specific pre-designated entrances and exits.
Security personnel or other designated members of staff will control
and screen who is allowed to enter or exit these areas as defined in
this guidance
Controlled Security personnel or other designated members of staff will control
Lockdown: Exit and screen who is allowed to exit the lockdown area as defined in this
Only guidance
Controlled Security personnel or other designated members of staff will
Lockdown: Entry control and screen who is allowed to enter the lockdown area as
Only defined in this guidance
Controlled Security personnel or other designated members of staff will control
Lockdown: Entry and screen who is allowed to enter or exit these areas
& Exit
Version 2.0 May 2019 24Lockdown Policy
HEATH LANE HOSPITAL
Physical Security
Immediately secure main front entrance door
Immediately ensure that any other fire exit doors are secure
Ensure that any ground floor (or first floor windows that are
accessible) are secured
Maintain a staff presence at all exit doors to ensure the secure
cordon is not compromised by unauthorised egress from site
Immediately inform PICU, GSC and Penrose so that the above can
be implemented, along with the securing of garden/courtyard doors
Immediately inform Scott House and Tredgold so that all of the
above can be implemented
Total Lockdown All perimeter doors/gates are secured and no one is allowed to
enter or exit the facility. Security personnel or other designated
members of staff will be assigned to key entrances and exits
Partial Only a specific part of a facility/building will be locked down.
Lockdown Everyone will be directed towards specific pre-designated
entrances and exits. Security personnel or other designated
members of staff will control and screen who is allowed to enter
or exit these areas as defined in this guidance
Controlled Security personnel or other designated members of staff will
Lockdown: Exit control and screen who is allowed to exit the lockdown area as
Only defined in this guidance
Controlled Security personnel or other designated members of staff will
Lockdown: Entry control and screen who is allowed to enter the lockdown area as
Only defined in this guidance
Controlled Security personnel or other designated members of staff will
Lockdown: Entry control and screen who is allowed to enter or exit these areas
& Exit
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PENN HOSPITAL
Physical Security
Immediately secure main front entrance door
Immediately secure rear door and deactivate automatic opening
Immediately ensure that any other fire exit doors are secure
including exit doors leading from ward corridor (136 etc.)
Ensure that any ground floor (or first floor windows that are
accessible) are secured
Maintain a staff presence at all exit doors to ensure the secure
cordon is not compromised by unauthorised egress from site
Inform The Beeches to replicate the above actions to deactivate
automatic front and rear door
Inform all wards in relation to garden/courtyard access doors
Inform Jasmine, Juniper, The Willows, The Groves and
Stores/Catering to replicate the above actions
Total Lockdown All perimeter doors/gates are secured and no one is allowed to enter
or exit the facility. Security personnel or other designated members of
staff will be assigned to key entrances and exits
Partial Lockdown Only a specific part of a facility/building will be locked down. Everyone
will be directed towards specific pre-designated entrances and exits.
Security personnel or other designated members of staff will control
and screen who is allowed to enter or exit these areas as defined in
this guidance
Controlled Security personnel or other designated members of staff will control
Lockdown: Exit and screen who is allowed to exit the lockdown area as defined in this
Only guidance
Controlled Security personnel or other designated members of staff will
Lockdown: Entry control and screen who is allowed to enter the lockdown area as
Only defined in this guidance
Controlled Security personnel or other designated members of staff will control
Lockdown: Entry and screen who is allowed to enter or exit these areas
& Exit
Version 2.0 May 2019 26Lockdown Policy
Appendix 4
Lockdown Incident Log
Date Time Action/Incident/Instruction(given by Name Signature
whom)
Version 2.0 May 2019 27Lockdown Policy
Policy Details
Title of Policy Lockdown Policy
Unique Identifier for this policy BCPFT-SEC-POL-01
State if policy is New or Revised Revised
Previous Policy Title where applicable n/a
Policy Category
Clinical, HR, H&S, Infection Control etc.
Security
Executive Director Executive Director of Nursing, AHPs and
whose portfolio this policy comes under Governance
Policy Lead/Author
Job titles only
Local Security Management Specialist
Committee/Group responsible for the
approval of this policy
Health and Safety Committee
Month/year consultation process
completed *
January 2020
Month/year policy approved March 2020
Month/year policy ratified and issued March 2020
Next review date May 2022
Implementation Plan completed * Yes
Equality Impact Assessment completed * Yes
Previous version(s) archived * Yes
Disclosure status ‘B’ can be disclosed to patients and the public
Potential threats, Levels of lockdown,
Activating a lockdown, Staff deployment,
Key Words for this policy Stand down, Vulnerability assessment, Total
lockdown, Partial lockdown, Controlled
lockdown, Action cards
* For more information on the consultation process, implementation plan, equality impact
assessment, or archiving arrangements, please contact Corporate Governance
Review and Amendment History
Version Date Details of Change
Policy fully reviewed with amendments to section 4.0 & 7.0,
2.0 May 2019 amendment to site details (Appendix 1) and Addition of Appendix
3&4
1.0 Feb 2016 New policy for BCPFT
Version 2.0 May 2019 28You can also read
