SECURITY MANUAL

SECURITY MANUAL

Prepared by:

K Harrison, S Kendrick, C Fraser, A Hilton, T Hoy

Issued: 11/97; 7/99, 4/06, 3/08, 6/09 Rev. No: 4 2011

Authorised by: ..
John F. Krygger, Chief Executive Officer

Rev. Date:

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GUIDELINES
Overview of Security Risk Management: For the purposes of this document, security risk management refers to the systematic application of management policies, procedures and practices to the tasks of establishing the context and identifying, assessing, controlling, monitoring and communicating risk. Security risk management encompasses the assessment of all aspects of the clinical and non-clinical environment, including consideration of internal and external risks. The Occupational Health & Safety Act 2004 (the OHS Act) and the Occupational Health and Safety Regulation 2007 (the OHS Regulation) require employers to identify the hazards, assess the risks arising from the hazards in their workplaces and develop strategies to eliminate or control these risks. This process is referred to as risk management. Risk management consists of four steps: Step 1 Step 2 Step 3 Step 4 - Hazard Identification - Risk Assessment - Risk Control - Monitoring and Review

The security risk management process should be undertaken, in consultation with staff, by individuals who have expertise in the areas being assessed. Ideally, a multidisciplinary team of clinical, non-clinical and security experts will undertake the appropriate aspects of the process. Consultation as an Essential Part of Risk Management: The OHS Act and OHS Regulation outline consultation requirements in relation to occupational health, safety and welfare and should be referred to when establishing consultative arrangements. The purpose of consultation is to enable staff to contribute to decision making that affects their health, safety and welfare at work. In particular, the OHS Act requires employers to consult with their staff on local consultation mechanisms for OHS. Consultation is a pivotal activity of all stages of the risk management process. Staff are most likely to know the risks associated with their work and may be in the best position to suggest effective controls. During the security risk management process, consultation should also occur with other appropriate stakeholders such as police and security professionals. Staff involvement in the risk management process will help ensure ownership of, and commitment to any changes to work procedures, practices, equipment or environment directed towards improving personal and property security. Effective consultation involves both staff and unions. Consultation can occur through formal and informal processes and may involve direct or representational participation. Important consultative forums are the Occupational Health and Safety Committee and/or OHS representatives.

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Step 1 Security Hazard Identification: In order to eliminate or control factors that can affect the security of people and property, a structured process for identifying security hazards that exist in the workplace needs to be undertaken. Security hazard identification is the process of identifying all situations, procedures, events or factors in the workplace and during the course of work (including the design of premises and during work related travel) where security hazards could cause physical or psychological injury and illness, the unauthorised disclosure of information or loss of or damage to property. The OHS Regulation 2007 makes specific reference to the requirement that employers take reasonable care to identify hazards arising from the potential for workplace violence. To ensure that all aspects of the work system and environment are considered, security hazard identification should include: Observing tasks being performed Reviewing incident, first aid and workers compensation statistics, incident reports, hazard reports and any other available data Reviewing results of recent security incident investigations Reviewing results of recent duress response operational reviews Consulting with staff in the workplace to determine what they think the hazards are (the needs/issues for casual/agency staff, volunteers and students on placement should be considered) Consulting with other stakeholders as appropriate, including external agencies (e.g. police) Observing the work area being assessed to see and hear what is happening Formal workplace inspections and security audits Developing scenarios about what could happen in the event of a security incident; and Analysing violent incidents and security breaches in line with the requirements of the OHS Regulation 2007. Employers are required to ensure that effective procedures are in place and implemented to identify security hazards: Immediately prior to using the premises for the first time as a place of work Before changes to work practices and systems of work are introduced While work is being carried out When new or additional information from an authoritative source relevant to the security of the employees of the employer becomes available.

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Step 2 Security Risk Assessment: Security risk assessment is the process of determining how likely it is that someone might be harmed, injured or there is a risk to their health and safety. The OHS Act 2004 requires employers to assess the risk of harm to the health or safety of staff and any other people at the employers place of work (e.g. patients and visitors) Factors to consider in assessing security risks are: Extent of exposure to the hazard (frequency and duration) Severity of potential injury/illness or loss associated with the risk Likelihood of injury/illness/loss/damage occurring Number of people/amount of property at risk; and Existing control strategies. The process of assessment involves: Consulting with staff and their representatives Examining the experience of the workplace or other similar workplaces including a review of incident data and near misses and other information such as prosecution decisions Reviewing relevant guidance material, industry codes of practice and Australian Standards; and Reviewing hazard information such as Material Safety Data Sheets or manufacturers information. South West Healthcare Quality / Risk Manager should be consulted to identify the risk assessment tools currently used within the organisation. Part of the assessment process is the prioritisation of risks for action. A range of tools are available to assist in prioritising risk. Step 3 Security Risk Control: Security risk control is the process of implementing appropriate measures to eliminate or reduce risks to personal and property security. Eliminating the hazard is the most effective way of controlling risk. Where elimination is not possible the OHS Regulation 2007 requires employers to take the following measures in the order presented to minimise security risks to the lowest level reasonably practicable: 1. Substituting the hazard giving rise to the risk with a hazard that gives rise to a lesser risk 2. Isolating the hazard from the person put at risk 3. Minimising the risk by engineering means 4. Minimising the risk by administrative means 5. Using personal protective equipment. Where a single measure is not sufficient for minimising risk to the lowest reasonably practicable level a combination of the above measures is required. Examples of security risk control strategies may include:

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Engineering Controls: Minimising security risks by utilising building design principles (Crime Prevention through Environmental Design CPTED) Replacing breakable glass panes and mirror with shatterproof glazing Installing security glass or metal screens to protect staff Installing video intercoms at night entrances Installing door and perimeter alarms and fixed and/or personal duress alarms Introducing technological tracking systems for community health staff Use of calming or non stimulating colour schemes. Administrative Controls: Providing training to assist with identifying the early warning signs of violence and defusing the situation before it escalates Developing policies or changing work practices so that two people answer the door at night, staff do not work alone or in isolation and escorts to car parks are available after dark Developing access and key control procedures Developing treatment and management protocols for violent patients. Rearranging tasks, activities or staffing to address identified potential times for increases in violence (e.g. staggering meal times in mental health units); and Applying procedures on harassment, bullying and grievance management. Personal Protective Equipment: Personal protective equipment can be defined as any equipment worn or held by the staff member to protect him/her against one or more health or safety risks in the workplace. Mobile duress alarms are available to all staff if required. Priority Workplaces: Within the health workforce a number of priority areas exist where the likelihood of security incidents occurring may be increased. These areas may include emergency department, maternity unit, individual patient specialling, mental health facilities, community health centres, drug and alcohol services, pharmacies and car parks. It is essential that the hazards identified, in these areas are dealt with as a priority and the effectiveness of risk control strategies is regularly monitored. Step 4 Monitoring and Review: To ensure that the outcomes from the security risk management process continue effectively addressing security issues, monitoring and evaluation of risk control strategies should be undertaken. Security risk monitoring and review involves: Regularly examining the workplace for new risk factors and taking appropriate action where they are identified; and Reviewing existing risk assessments and any measures adopted to control the risk.

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The Occupational Health and Safety Regulation 2007 require employers to review an existing risk assessment and any measures adopted to control the risk whenever: There is evidence that the risk assessment is no longer valid Injury or illness results from exposure to a hazard to which the risk assessment relates A significant change is proposed in the place of work or in work practices or procedures to which the risk assessment relates. It is also advisable to periodically review risk assessments and control strategies to ensure they remain relevant and effective. Hazard and Incident Reporting, Management and Investigation: Effective hazard and incident reporting, management and investigation provide information to assist with monitoring, reviewing and evaluating South West Healthcares security programs by highlighting new risks and identifying the effectiveness of current control strategies. Hazard Reporting: As an essential part of a risk management system, all staff are required to report problems as soon as they notice them using the appropriate hazard forms. Incident Reporting: All security related incidents should be reported and recorded using the Riskman Incident Reporting database. Depending on the nature of the incident, it may need to be reported to the Chief Executive Officer, the Department of Human Services or external agencies such as the Police or the Victorian WorkCover Authority. Incident Management: All security related incidents need to be efficiently and effectively managed. Incident Investigation: The most effective way to prevent a recurrence of a security incident is to determine why it happened (i.e. identify the contributing risk factors) and take steps to prevent its recurrence (i.e. eliminate the risk or develop and implement control strategies). Incident investigations should: Be carried out promptly Be conducted in a supportive and non judgemental way Focus on identifying the underlying root cause/s and contributing factors Not apportion blame Focus on system breakdowns and identifying control measures to prevent recurrence Be undertaken by managers in consultation with those involved (with the involvement of specialists where required) Canvas all sources of relevant information (e.g. witnesses, incident reports, relevant work policies and procedures, the working environment, equipment used, level of supervision at the time, relevant training provided and expert advice) Include an operational review if relevant; and

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Result in clear recommendations to senior management to address the causes and where possible to prevent a recurrence. It is crucial to the success of the investigation process that it results in clearly articulated recommendations to prevent a recurrence, identifies resource implications (if any), identifies who is responsible for the implementation of the recommendations and outlines appropriate timeframes. Injury Management: The loss or disruption that can result when an incident occurs in the workplace can be multiplied when that incident leads to an injury to staff or a patient/visitor. A comprehensive, effective security program should therefore address what needs to happen if an injury occurs. Two key factors that interact to reduce the effect of a workplace injury for the injured staff and the employer are early intervention and early return to work.

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1.

SECURITY RISK MANAGEMENT IN THE PLANNING PROCESS POLICY:

Security issues are considered and addressed, using a risk management approach in all formal and informal planning processes, including the development of: Strategic plans Business plans Service development plans Disaster/emergency plans Project definition plans (as part of facility planning) Procurement processes, including processes for procuring services, premises, equipment, furniture, fixtures and fittings; and OHS improvement and management plans.

2.

HEALTH FACILITY DESIGN STANDARDS:

Policy: It is policy that the standards outlined in South West Healthcares Security Guidelines are adopted during all stages of the capital design/refurbishment process. Where changes are being made to the local working environment, South West Healthcare will ensure in consultation with staff and any key stakeholders, that all reasonably foreseeable security risks are identified, assessed, eliminated where reasonably practicable or effectively controlled.

3.

SOUTH WEST HEALTHCARE LEASING OF PROPERTY TO OR FROM EXTERNAL PARTIES POLICY:

South West Healthcare must ensure in consultation with staff and key stakeholders, that all reasonably foreseeable security risks associated with: Leasing property for use by the organisation; or Leasing health facility premises to external organisations are identified, assessed, eliminated where reasonably practicable or effectively controlled, that the process is appropriately documented and arrangements for security included in leases.

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4.

SECURITY ARRANGEMENTS FOR PATIENTS IN CUSTODY POLICY:

As part of the facility security risk management process South West Healthcare must ensure in consultation with staff and relevant external department (i.e. Department of Corrective Services, Department of Juvenile Justice and Victoria Police), that: All reasonably foreseeable security risks associated with patients in custody are identified and assessed. Effective security procedures for eliminating or controlling security risks, which are consistent with the operational controls of the relevant external departments are developed and implemented. The procedures are appropriately documented and communicated to relevant staff. Guidelines: The security of patients who are in custody is the responsibility of the Department in whose custody they are held. South West Healthcare has a behavioural assessment room located in the Emergency Department which should be utilised in these situations.

5.

SECURITY EDUCATION AND TRAINING POLICY:

South West Healthcare must ensure that: All staff are provided with appropriate security related education and training, including violence prevention and management training, consistent with legislative requirements as part of South West Healthcare security risk management program Education and training are appropriate to the role of the staff member and targeted to the level and type of security risk that may be encountered in the course of their work; and Details of security related education and training conducted within South West Healthcare are documented and maintained. Legislative Framework: Under the Occupational Health and Safety Act 2004 and the OHS Regulation 2007, employers are required to provide information, instruction, training and supervision necessary to ensure the health and safety of staff. Professional Assault Response Training: South West Healthcare may determine, via the risk assessment process, that Professional Assault Response Training (PART) is necessary for a particular group/s of staff. Professional Assault Response Training should complement other risk control strategies and should only be considered after all other practical violence prevention strategies have been implemented. Such a decision should only be made after the following considerations:

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Have all other possible risk control strategies aimed at preventing violence occurring and protecting the target group been implemented? Does the level of risk faced by the target group warrant provision of evasive self defence training (e.g. do the risks faced by the group outweigh the risks/costs associated with providing evasive self defence training?). Professional Assault Response Training should be developed and delivered by experts and be targeted to the needs of the group being trained. Where the decision is made to provide, Professional Assault Response Training (PART), the training should: Emphasise retreat, escape and self protection Cover legal issues associated with evasive self defence including the concept of reasonable force Be developed and delivered by appropriately experienced and accredited experts Provide techniques that are relevant to the tasks of the target group, the risks faced by the group and the environment in which it operates Include the need for and provision of regular practice Consider the physical characteristics of the target group and those of the perpetrators of violence where possible Include the dangers and precautions when using evasive self defence. Duress Response: Staff who form part of a pre-determined duress response will require specific training to enable them to undertake this role effectively. This training may include: The process for duress response Assessing a scene Verbal de-escalation Negotiation skills Professional Assault Response Training, including physical restraint techniques, use of mechanical and other restraints where appropriate and associated legal implications The Emergency Controller (Clinical Co-ordinator) requires specific training in crisis communication and defusing.

6.

ACCESS CONTROL POLICY:

As part of the facility security risk management process, South West Healthcare must ensure in consultation with staff and key stakeholders that all reasonably foreseeable security risks associated with access to workplaces are identified, assessed, eliminated where reasonably practicable or effectively controlled. South West Healthcare must ensure that this process is appropriately documented and effective access control procedures including the implementation of staff identification systems are developed and implemented.

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Guidelines: In general effective access control involves: Appropriate securing of perimeters including doors and windows Appropriately controlling access to the land on which the facility is situated (e.g. fences, roads, traffic and pedestrian access and flow) Providing safe access and egress, especially after hours and during emergencies Controlling access to vulnerable areas Clear signage; and Instituting staff identification systems that allow members of the organisation to be identified. Access control systems are: Secure enough to resist attempts to breach the system Able to effectively differentiate between those who have authorised access and those who have not Reliable (i.e. there are no weak links in the system) regularly maintained and tested Inclusive of a backup system or process for providing access in the event of failure (key override locking process). Signs: Signs are the first line of defence against intruders because they define those areas where persons are allowed to enter. Security Systems: To allow staff to identify and communicate with persons at the entry doors to the premises, South West Healthcare has installed a CCTV system in areas where it is seen to improve the security of staff. The feature of the system should be advised by the risk assessment process and may include: Camera points located outside the entrance to the Emergency Department Entry doors fitted with locks that can be opened electronically from the monitoring point within the building. Staff should be cautious in allowing entry into the building particularly after hours. The need to escort the person seeking entry to their destination needs to be considered. Personnel and Contractor ID Systems: Identification cards may contain any or all of the following features, bearing in mind, integration of existing systems and the outcomes of the risk assessment process. Administration of an Identification/Electronic Access Control System: The following should be considered in the administration of an identification/electronic access control system:

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The Human Resource Department issues staff identification cards. The issuing department should hold the records and arrange updating and reissue or replacements as necessary All documentation and equipment for identification systems should be securely stored by means that prevents unauthorised access Clearance procedures on termination need to include the return of the staff identification cards and keys. It may be necessary to recover the permanent identification card and any keys, then issue a temporary card valid until the final day of employment only, when it should also be returned. Electronic Access Control cards and keys are issued by the Facilities Department and records of cards / keys issued kept on master register.

7.

KEY CONTROL POLICY:

As part of the facility security risk management process, South West Healthcare has ensured in consultation with staff and key stakeholders, that all reasonably foreseeable security risks associated with key control have been identified, assessed, eliminated where reasonable practicable or effectively controlled. South West Healthcare has determined that the process is to be appropriately documented and that effective key control procedures have been developed and implemented. Guidelines: South West Healthcare has developed procedures in consultation with staff and other stakeholders, to effectively manage key control. The aim of these procedures is to protect people and assets and minimise the likelihood of incidents related to theft and assault.

8.

ALARM SYSTEMS POLICY:

As part of the facility security risk management process, South West Healthcare must establish their requirements for alarm systems (e.g. duress and intruder alarms) to ensure that staff members, patients and South West Healthcare assets are secure. A regular review of all alarm systems must occur as part of the risk management process. In assessing the requirement for alarms, South West Healthcare should consider the following issues: Potential for violence against staff The type of work being carried out by staff Working in isolation Cash handling Goods and equipment stored in the area Level of external security risks Level of internal security risks Exits that may be left open by staff or patients The security needs of at risk patients such as wandering elderly patients in wards, or children at risk of unauthorised removal from the facility

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Potential for use of emergency exits (e.g. fire escapes) by thieves to remove assets Potential for break in via doors and/or windows to remove assets; and Potential for break into and theft of vehicles. In assessing the requirement for alarms, South West Healthcare will consult with staff working in these relevant areas. In identifying appropriate alarm systems, South West Healthcare should ensure that, where appropriate: The alarm system complements any other protective measures taken by the facility The alarm system features and configuration are appropriate to the identified needs and possible risk. Duress Alarms: A duress alarm is a signal for assistance sent by a person(s) who is under attack or threatened by the situation they face. Modern duress alarm systems use a combination of electromechanical, electronic, radio frequency and digital devices to send and receive the signals. The advantage of these types of duress alarm systems is that South West Healthcare can identify the location of the person requiring assistance. The expertise of independent technicians or consultants is required to prepare the necessary specifications and system design when implementing duress alarm systems. The type and level of sophistication of duress alarms should be advised by the risk assessment process. Installing a Duress Alarm: When installing a duress alarm identify the characteristics required of the duress alarm by considering the following: Fixed alarms, with duress buttons strategically located throughout the health care facility Mobile duress alarms worn by staff members within the health care facility Mobile duress alarms worn by staff members who regularly work outside the health care facility. Fixed alarms may be used in well defined areas where there is no or little opportunity for an aggressor to get between a staff member and the alarm button and the person works from a static position (e.g. where staff are behind a screen such as a pharmacy distribution window or behind a counter). Fixed alarms may not be appropriate for areas accessible to patients and the public (e.g. corridors, as mischievous tampering with alarms may occur). Mobile duress alarms may be used where the staff member is mobile in the course of their work in areas such as wards or emergency departments where there is a risk of being confronted by aggressive behaviour.

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Mobile duress alarms should be worn attached to the clothing (e.g. clipped to a pocket). They should not be worn around the neck. Duress alarms should only be used in the area they are intended for use. Do not take duress alarms out of any area. Mobile duress alarms for use within a facility and the immediate area should comply with all relevant Australian and regulatory requirements including Austel approvals, AS2201 and AS3000 as an absolute minimum especially in relation to installation, servicing and wiring of all equipment and systems. The risk assessment of the area to be serviced by the mobile duress alarm informs the sorts of features necessary for that particular system. The most effective mobile duress alarms have the following features: Be dual activated (i.e. have two activation mechanisms, those being activated by pushing a single button using one finger and activation by the staff member falling down/not moving but allowing reasonable movement. When activated, automatically alerts the duress response team regardless of where their members may be located. Alerts other staff in the work area/facility that a colleague requires assistance, to ensure that assistance is activated and to ensure that another staff member does not accidentally walk in on a duress situation thus putting themselves at risk. The alert should be by: notifying a central processing unit where a visual display identifies the location of the staff member who has activated the duress; and/or providing the alert (including location) on an alphanumeric pager carried by the response staff; and/or providing a visual or audible alert e.g. strobe light or passive siren located so as to alert the response team and not the aggressor.

Have suitable battery functions, such as: - a low power indicator (easily distinguishable) - minimum 24 hour battery life without replacement or recharge - water resistant - able to operate between temperature ranges of 0 to 45 centigrade Be able to interface with other local communication systems (e.g. paging systems) Be able to cover all working and amenity areas for the specific location including meal rooms, toilet facilities, stairwells, storerooms and external staff amenities (e.g. car parking) Provide integrity of communication and a system which is not prone to interference or false alarm Provide accurate information on the location of a staff member to within 5 metres inside health care facilities and to within 10 metres outside of health care facilities.

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Include off the shelf quality tested equipment rather than customised equipment or software: Be of current technology and part of a system that can be easily added to or subtracted from if needs change (e.g. staff leave or join, without needing to install a new range or design of equipment) Be of self-testing capacity, with each self-test carried out at intervals of one hour or less Be small, light, water and vandal resistant, of robust build and able to withstand every day operational rigours including dropping the device or splashing the device, etc. Include a warning indication if the user is out of range, communications or battery failure Be capable of transmitting a duress signal to other staff members within five (5) seconds of activation with a reliability factor of no less than 98% for indoor situations and within 30 second for an outdoor alarm Be guaranteed by the supplier of the duress system (i.e. all equipment and systems will be supported for a period of no less than five (5) years from the date of service and the supplier needs to provide urgent and routine servicing and replacement of all parts during that period) Be user friendly and simple to use. Where the risk assessment process identifies gaps in the existing duress alarm system and the cost of replacement is significant, other risk control strategies should be implemented to complement the existing system. Training: Suppliers of any alarm system should, as part of any contract, provide training for staff in the use of the equipment.

9.

LIGHTING:
Policy: As part of the facility security risk management process, South West Healthcare must ensure in consultation with staff and key stakeholders, that internal and external lighting is sufficient to eliminate where reasonably practicable, or control security related risks and meet the relevant Australian Standards. Guidelines: Security lighting is internal and external lighting that is used to improve security in the vicinity of the light. The external lighting system recommended for health facilities uses luminaries of the High-Pressure Sodium (HPS) type.

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Security Risk Management: Ensuring external security lighting is in vandal resistant containers and mounted to restrict tampering (e.g. too high up to be readily broken) Ensuring posts for security lights are designed in such a way that they do not provide a ladder or foothold to allow access to the light fitting Ensuring security and other staff are provided with a system for reporting malfunctioning lights Ensuring malfunctioning lights are replaced immediately Ensuring security lights can be automatically activated and deactivated at pre-set times (times need to be seasonally adjusted) Ensuring security lights are connected to an electrical circuit separate to that of the main facility Ensuring some internal lighting remains on during the night Locating and styling lights so as to gain the maximum benefit and coverage Providing lights bright enough to ensure a safe entry to and safe exit from the workplace (including footpaths/access ways) and providing acceptable levels of light in car parks. Lighting should avoid creation of dark spots and be sufficiently bright to deter crime and to provide sufficient illumination to prevent slips, trips and falls and allow facial recognition. Where the facility does not have dedicated onsite parking, consultation on street lighting should occur with local councils Ensuring lighting used meets Australian Standards AS1680 series, AS1158 series (including 1158.3.1), AS4485.1 and AS2890 where applicable Determining the needs of areas requiring special lighting treatment (e.g. entrance foyers, emergency departments, staff entry and exit points, pharmacies and car parks) Ensuring a back up generator is available where practicable, to ensure continuity of electrical supply for security lighting Consulting with neighbours who may be affected by security lighting.

10. WORKPLACE CAMERA SURVEILLANCE:

Policy: South West Healthcare must ensure in consultation with staff and key stakeholders, that where workplace camera surveillance is used as part of the facility security risk management program, effective procedures are developed and implemented that are consistent with relevant legislation. When implementing this policy, the relevant legislation is Surveillance Devices Act 1999 in detail. Definitions: Camera surveillance which may be overt or covert, relates to surveillance activities undertaken using video or camera equipment. Overt camera surveillance involves the use of unconcealed surveillance equipment, signposted to draw attention to the fact that an individual is under observation. Legislation: Surveillance Devices Act 1999: no specific focus on workplaces restricted application to workplaces due to: a. exemption where consent to surveillance readily obtained by employers b. exemption where no reasonable expectation of privacy employers can easily remove
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Guidelines: Within South West Healthcare there are potentially two types of camera surveillance that may occur: Overt camera surveillance to observe staff Overt camera surveillance in relation to personal or property security. Overt Camera Surveillance: Risk Assessment As identified in previous chapters of this policy, South West Healthcare should undertake a risk assessment to identify security risks and determine and implement appropriate controls to eliminate or minimise the risks. As camera surveillance is considered to be a risk control strategy that is toward the lower end of the hierarchy of risk controls e.g. an administrative control, South West Healthcare must ensure that, as far as practicable, all other appropriate risk control strategies higher up the hierarchy are put in place to control security risks. General Issues for Overt Camera Surveillance: Security related Workplace Camera Surveillance Objectives of camera surveillance: In the security context, camera surveillance is generally used to achieve the following objectives: To deter security incidents e.g. theft, vandalism, violence, etc. To gather information that may be used in evidence if a crime is committed within view of the camera (assuming the camera is recording) To allow a security incident to be viewed as it is occurring and an appropriate response to be raised. Regardless of the reasons for the installation having a clearly displayed camera in a particular area can create an expectation from staff and others that duress response will be automatically triggered if a violent incident occurs within view of the camera. As a result, this may affect the response of the individual to the situation e.g. not retreat as they are expecting assistance. Because of this potential, the following questions should be given serious consideration when determining if and where, to use overt camera surveillance: What is the primary purpose of the camera surveillance i.e. does the area have a history of vandalism because it is isolated after hours or the premises is largely unused; is it an area of opportunistic theft such as a retail out on any South West Healthcare property; is there a history of violence in the area? What expectations might the presence of the camera reasonably create in those using the area? What expectations might the presence of the camera reasonably create in those using the area? What level of monitoring is necessary and what is the availability of appropriately licensed and trained staff to undertake the monitoring? What information should be contained in the notification signage?

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If a camera is placed in an area with a history of violent incidents, or it is reasonably foreseeable that there may be future violent incidents in the area, it should not be assumed that the presence of the camera and signage will deter violence in all instances. Such instances may include where the perpetrator: Is under the influence of alcohol or other drugs Is suffering from a medical condition that may predispose the sufferer to violence Has a significant history of violence Is suffering from a particular mental illness. South West Healthcare has developed effective procedures for: Ensuring camera surveillance equipment remains appropriately placed and continues to be pointed in the necessary direction Maintenance and testing of the equipment a maintenance log is recommended Undertaking regular risk assessments to ensure that the introduction of camera surveillance has not created new or different security risks e.g. moved potential illegal activity from the area now under surveillance to other surrounding areas or created expectations in relation to a duress response that may be unrealistic or unable to be met. Note: at this time, overt camera surveillance is live only. Cameras are not monitored and not recorded.

11. PROVISION OF SECURITY SERVICES:

Role of Security Services: The duties of security staff will vary according to the type, location, size and local circumstances of the health workplace. However, in broad terms they are generally responsible for assisting with the security of staff, patients, visitors and assets of the health workplace. The security role should never be confused with that of a Police officer. Although security staff may assist police, the primary role of each service is different. The security officer/health and security assistant roles are South West Healthcare specific roles with a strong emphasis on prevention and assisting in the management of incidents. Security staff should not place themselves at unnecessary risk in carrying out their duties, regardless of their occupational role. In practice there may be times when the duty of care to patients or others may require intervention but at no time should the duty of care override a staff members right to safety.

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Using Force in the Execution of Duty: Security staff may be required to use physical force in the course of their duties. Physical force should be limited to: Assisting with the restraint of a patient at the direction or request of an appropriate staff member (e.g. nurse, medical officer, etc.) Evasive self defence as is necessary to protect themselves, with due regard to the concept of reasonable force; and The minimum force necessary to protect staff while observing their own safety. South West Healthcare through education and training strategies need to ensure security staff understand the concept of reasonable force and are aware that their actions may be scrutinised by a court of law. Evasive Self Defence: The law recognises that an individual may protect themselves or another person from a threat of attack or injury. The protection afforded by the law is limited to situations where: The person believes the action is necessary to defend themselves or another person; or The action is necessary to prevent or terminate unlawful deprivation of their liberty or the liberty of another person. In order to be lawful the conduct must be a reasonable response in the circumstances as he or she perceives them and there must be some reasonable proportion between the threat perceived and his or her response to it. The purpose of evasive self defence is to assist staff to escape from a violent situation when retreat is blocked, when all other non-physical strategies are inappropriate or have failed and the staff member is under attack or attack is imminent. When properly used, it may minimise the risk of injury and minimise the potential trauma. In these circumstances the behaviour of staff should be defensive rather than aggressive, controlling rather than punitive and with no more force than is necessary in the given situation. The degree of force used must be proportionate to the degree of potential harm faced and must not be applied for longer than is reasonably required to control that risk. Restraints: Restraints are human or mechanical actions that restrict a persons freedom of movement. The term chemical restraint is sometimes used to refer to the use of medication to sedate and control behaviour.

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Searching Patients and Visitors: To ensure the security of staff, patients and other visitors to South West Healthcare there may be circumstances where the searching of patients and visitors is considered an important risk control strategy. However, the power to search an individual is restricted to narrow circumstances allowed under criminal law and the Mental Health Act which are strictly regulated or when the individual consents. Without clear lawful authority any search initiated without consent would be a trespass upon the person and therefore unlawful. Where, after an assessment of risks (including the legal context), a health facility determines the need for procedures to search for weapons and other dangerous objects South West Healthcare should consider the following points. Under the Inclosed Lands Protection Act 1901 South West Healthcare as occupier of its premises, has the right to determine who may enter its premises, and is entitled to: Prohibited weapons, illegal drugs or alcohol are not to be brought into the facility South West Healthcare reserves the right to search persons if there is a reasonable suspicion that a person has brought such weapons or drugs into the facility A person who refuses to be searched when requested will be escorted from the premises. Any procedure should therefore ensure that persons entering South West Healthcare premises are aware of these conditions. The situation is somewhat different in relation to persons involuntarily detained under the Mental Health Act, which provides for the involuntary detention of persons suffering from a mental illness that place themselves or others at risk of serious harm. The objects of the Act include facilitating treatment and care and Section 31 (2) specially allows a detained person to be given such treatment as the medical superintendent thinks fit. This combination of provisions would authorise searching of involuntary patients where the search was directed towards care and/or treatment or prevention of harm to the patient or others and there is a reason to believe that the search is necessary. Introducing related policies would require clearly articulated procedures, comprehensive staff training and appropriate back up.

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Retention and Restoration of Weapons or Implements: On occasion people may present to South West Healthcare facilities carrying weapons or implements that give rise to security fears for staff. This can occur, in particular, in emergency departments where the fact that treatment has been sought in an emergency situation means people have not necessarily had an opportunity to organise their affairs and properly secure or remove weapons or implements. Circumstances may arise where a person may have a permit to carry a weapon or their occupation has been exempted from the Weapons Prohibition Act 1998 however, this does not entitle them to retain a weapon on South West Healthcare property if it causes staff to fear for their security. South West Healthcare must have procedures in place to manage issues associated with the retention of weapons. When developing these procedures, the following risk control strategies should be considered by South West Healthcare: People who hand custody of a weapon or implement to South West Healthcare staff should, where practicable, be offered a receipt for their property All weapons and implements should be placed in a plastic bag to protect any forensic evidence. Staff handling weapons and implements should wear gloves Should the weapon or implement fall into the category of a prohibited weapon, as defined by the Prohibited Weapons Act 1998, or carrying the weapon is against the law (e.g. juvenile with a knife), the police should be contacted and advised of the nature of the weapon and circumstances of retention. Security officers should fill out an incident report/or equivalent describing all details. This weapon should then be placed immediately into a designated safe until collected by police (refer to section below on Storage and Disposal of Weapons) If the weapon or implement does not fall into the category of a prohibited weapon but there are concerns regarding the nature of the weapon or implement (large knives, screwdrivers, slide hammers, etc.), the police should be contacted and advised of the nature of the weapon or implement and the circumstances of retention. Security officers should fill out an incident report/or equivalent describing all details. This weapon or implement should then be placed immediately into a designated safe until collected by police (refer to section below on Storage and Disposal of Weapons). Should the person have lawful rights to that weapon or implement and it is necessary to return it to them on their departure from South West Healthcare premises, then the usual practices for managing patients valuables should apply including: locking the weapon or implement into a safe and entering the details into a valuables book/or equivalent, including the name and address of the owner. The owner should be advised that they have a period to claim the weapon after which time it will be destroyed when returning the weapon or implement to the owner ensuring the item is signed for in the valuables book/or equivalent.

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Storage and Disposal of Weapons or Implements: South West Healthcare must have procedures in place for storing weapons or implements awaiting collection by the lawful owner or by police. When developing these procedures, the following risk control strategies should be considered by South West Healthcare: The weapon or implement should be placed into a designated safe which should be located in the department (or other appropriate area) where access is restricted to security personnel only The designated safe should be key operated. Security staff should have access to the safe to ensure that weapons or implements are secured immediately The safe should be emptied by a nominated senior staff member on a daily basis and the contents of the safe transferred to another safe which can be accessed by this senior staff member only. Weapons or implements are to be kept in this safe pending collection by the lawful owner, police or disposal Where a weapon or implement has not been collected by the lawful owner and the required timeframe for keeping property has expired, arrangements should be made by South West Healthcare for its disposal. Licensing Requirements for Security Staff: All security officers working at South West Healthcare are required to be licensed by the Victorian Private Agents Act 1966.

12. SECURITY IN THE CLINICAL ENVIRONMENT:

As part of the facility security risk management process, South West Healthcare will ensure, in consultation with staff and key stakeholders, that all reasonably foreseeable security risks associated with the clinical environment are identified, assessed, eliminated where reasonably practicable or effectively controlled. The process is appropriately documented where applicable in each clinical area. The aim of these procedures is to protect people and assets and minimise the likelihood of incidents related to robbery, abduction and violence. Additionally, clinical protocols should be implemented to manage aggression arising from a patients medical or psychiatric condition. Priority Areas: Within the clinical environment a number of areas exist where the likelihood of security incidents occurring may be increased. These areas may include emergency departments, maternity units, admissions areas, mental health services, drug and alcohol services, aged care/dementia units and during individual patients specials. The following risk control strategies should be considered:

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Building Design: Ensuring, where possible, that waiting areas: - Are comfortable, decorated in muted colours and are spacious - Have a clear path to commonly used fittings and facilities (eg phones, water and snack dispensers, toilets etc) - Have adequate signage, seating, ventilation and temperature control - Have furnishings that cannot be moved and/or used as weapons - Are well maintained (eg water and snack dispensers, lighting, phones are in working order and clean and tidy etc) Ensuring the design of desks, counters and screens are determined by their purpose and the degree of risk associated with the tasks and work area Ensuring interview rooms are designed to: - Include two doors (staff members should sit close to one of the doors, with furniture between them and the client and no obstruction blocking their exit, doors should open outward to facilitate quick exit of staff) - Have controlled access (but still allow for escape) - Include duress alarms - Include safety glass windows so staff can be seen while retaining client privacy Ensuring that waiting areas and common space in mental health units are sufficiently large to give people space and avoid the stress of overcrowding Avoiding the creation of isolated work areas when designing facilities (eg do not isolate work areas that are 24 hours by separating them with work areas that are only occupied in the day time or Monday to Friday) Positioning the nurses station to allow for an unobstructed view of the entries/exits to a ward.

Access Control: Implementing a system for securing and answering the access doors Providing a secure means of delivering a service after hours Ensuring departments/units/wards and staff only areas are appropriately signposted to ensure ease of access and reduce the likelihood of people using being lost as an excuse for trespass. This includes consideration of the use of multi-language and/or international symbol signage. Assessing the need to install: - Video surveillance at entrances, including ambulance bay doors and in clinical areas (eg nurseries) - Intercoms at entrances - Duress alarms

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Patient Liaison and Management: Developing procedures for limiting the number of patient support people/visitors in treatment areas Developing procedures for communicating with and monitoring waiting patients and waiting family members Developing appropriate criteria and protocols for admission, assessment and transfer of patients particularly first assessment of patients and seeking and assessing any relevant risk information from services transferring, or the provision of information to services receiving the transferred patient Developing, in consultation with staff, guidelines on patient triage, assessment and treatment/management protocols to reduce risks of aggression of medical origin (eg clinical guidelines/protocols for the diagnosis and management of mental illness, dementia, effects of alcohol and other drugs, delirium, brain injury etc) and making these readily available to staff Implementing clinical and non-clinical protocols for preventing and managing violent behaviour Documenting and analysing violent incidents Conducting operational debriefings after an incident to ensure protocols were followed, equipment worked properly and that these were adequate to manage the event Establishing a well designed, well staffed, secure therapeutic environment which is compatible with clinical care objectives Implementing a patient alert system Developing communication strategies for ensuring that patients and visitors are aware of their behavioural responsibilities and the consequences of not meeting those responsibilities Developing processes for providing information and explanations to patients and those waiting (eg information on delays in procedures and timing to assist in reducing the risk of violence). Security Services: Implementing a system of security patrols/response which includes assessing the need for the allocation of security staff to priority areas and/or at higher risk times. Staffing Issues: Ensuring sufficient staffing levels to provide prompt clinical care, particularly during peak activity cycles to reduce the risk of violence from frustration, pain and/or boredom Ensuring adequate staff levels to allow the early recognition of potential for aggression, to deter violence and to provide for a response in duress situations. Education and Training: Ensuring that training is provided for all relevant staff, including security staff, in: - Minimisation and management of aggression - Duress response - Emergency response procedures (eg fire, bomb, abduction)

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Staff Awareness: Ensuring relevant staff are aware of their responsibility to: - Comply with all established security procedures - Implement work practices - Report workplace hazards - Participate in appropriate training in the minimisation and management of aggression and duress response - Report all violent incidents as per local protocols - Assist others if it is safe to do so and - Behave appropriately towards patients and other staff and provide patients and their family members with adequate information Recommending appropriate dress codes (eg avoiding dangling jewellery or clothing that could be grabbed during an attack and ensuring that identification tag necklaces are of the breakaway kind to avoid injury if grabbed by an assailant). Responding to Violence: To appropriately respond to violence: Ensuring that staff are aware of and equipped to utilise options for responding to violence, theft and robbery (for more information refer to SWH MAPPs policy Zero Tolerance) Ensuring the implementation of a system for responding to duress incidents/alarms Ensuring agreement is reached with other external emergency services regarding the management of violent situations (eg hostage situations) Identifying and installing appropriate duress alarm technology and implementing protocols for their use and maintenance Ensuring appropriate patient triage, assessment and treatment/management procedures are developed and implemented to reduce the risks of violence of medical origin Implementing post-incident protocols, including immediate response, treatment of physical injuries and support for affected staff and patients Patient Restraint: Sometimes it is necessary for patients to be restrained to protect them from hurting themselves or others. Under the direction of clinical staff, security staff may assist with the restraint of patients. However there may be occasions where security staff may need to act without the direct instruction of clinical staff. Such situations would be rare and would be limited to acute emergency situations where: There are no clinicians in the immediate vicinity at that particular moment, and where failure to act immediately will clearly result in injury or trauma or Clinical staff are unable to issue instructions (eg they are injured or incapacitated). It is expected that this would be for brief periods of time only and at all times the principle of reasonable force is to be adhered to.

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Non-metallic, soft or leather restraints supplied by a medical appliance company are the only acceptable mechanical restraints to be used by security officers or others when directed by a clinician to restrain a patient in this way. Residential aged care: provides restraint free environments wherever possible. The use of restraints should only be as a last resort to prevent harm to the individual, other residents and staff and to optimise the residents health status. See the Restraint Minimisation clinical guideline for further information. Newborns: For security issues related to newborns, consider the following additional strategies as specified in Australian Standard 4485.2 1997 (Security for Health Care Facilities, Part 2: Procedures Guide): Taking footprints of each newborn Taking a clear, high-quality, head and shoulder, colour photograph of the newborn Maintaining a full written description of the newborn, which should be kept with the footprint and photograph and entered as part of the newborns medical record Ensuring all hospital personnel (including senior management) wear conspicuous ID cards in the nursery and other newborn areas Using a distinctive code or second ID card for those authorised to handle newborns Ensuring that anyone transporting the newborn outside the mothers room wears the appropriate identification Ensuring that the newborns are always supervised by either the mother or health care personnel Ensuring the identification of the person taking the newborn home from the hospital is sighted and the childs band is matched with that of the parent Ensuring newborns are taken to mother one at a time rather than in a group Making sure newborn T-shirts or gowns and the newborns blankets in all four corners have the hospital name and logo Instructing hospital personnel to ask visitors the name of the patient they are visiting Ensuring that the mothers or the newborns name is not visible to visitors.

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13. SECURITY OF STAFF WORKING IN THE COMMUNITY:

Definition of community: Clients home, the community health centre, the road and pathways between these venues. South West Healthcare is required to have policies and procedures in place to ensure the safety of staff working in the community and staff are required to adhere to these policies and procedures which have been developed in consultation with staff. Staff members will undertake a home visit risk assessment prior to undertaking a home visit and according to the risk assessment will follow the relevant pathway as described in the risk assessment. (MR OP30) A home visit by community health staff will take place with the consent of the patient and carer. Where no consent is given, this will be noted on the risk assessment form, and in the medical record. All staff members on leaving the community health centre will advise the relevant person in their agency where they are going, expected time of return and ensure that they have a mobile phone with them. Staff members should be alert and assess the situation when making home visits and if dont feel safe then leave. All motor vehicles are required to be maintained and have regular services as per vehicle maintenance book and MAPPs 5.7 Motor Vehicle Policy. In the event of a vehicle breakdown or accident, the staff member should notify their relevant community health campus and contact the motor vehicle assistance service ( details should be in each vehicle). Each community health campus is required to undertake a security risk assessment and develop controls to address identified risks relevant to each campus. In the advent of a security incident occurring in a community health centre the staff member should ring 000 if an emergency and request police assistance. The location of fixed duress alarms should be known by all staff in the community health campus and the mode of operation. Staff members that are not working near a fixed duress alarm and may be working in different areas in the building should wear a duress alarm. When staff are working out of normal operating hours and the community health centre is not normally operating then a system is required to track those staff members and ensure that the staff member has safely completed their work and left the community health centre.

14. SECURITY IN RURAL AND REMOTE SOUTH WEST HEALTHCARE SITES:

Where different from Section 18: See MAPPs Working In Isolation

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15. SECURITY IN THE PHARMACY:

As part of the facility security risk management process, South West Healthcare will ensure, in consultation with staff, key stakeholders and appropriate advisory bodies, that all reasonably foreseeable security risks associated with pharmacy areas are identified, assessed, eliminated where reasonably practicable or effectively controlled. South West Healthcare will ensure that the process is appropriately documented and effective procedures are developed and implemented.

Guidelines:
The pharmacy is an area requiring high security. South West has developed procedures, in consultation with staff and other stakeholders, to effectively manage pharmacy security risks. The aim of these procedures is to protect people and assets, prevent and detect drug diversion and minimise the likelihood of incidents related to robbery and assault occurring in pharmacy areas. As part of the risk management process for the pharmacy area, the following risk control strategies should be considered: Constructing walls, floor and ceilings of the pharmacy out of solid material, with as few windows as possible Extending walls, where practicable, to the underside of the floor slab above to prevent any intrusion over the wall Reinforcing windows on the perimeter walls to prevent entry. Existing windows may be reinforced by adhering a shatter resistant film or by replacing the glass with laminated glass. Incorporating laminated glass windows into the design of the front of the pharmacy to enable staff to carry out transfer operations with safety, while maintaining communication with staff and patients Designing a two door entry approach (ie one door for the public and hospital staff to enter to access front glass transaction windows and a separate door for the entry of pharmacy staff to the pharmacy) Incorporating provision for closing off open areas at the front of the pharmacy when closed, (eg by a locked door from the corridor or locked shutter doors) Fitting doors to the pharmacy with quality single cylinder dead locks to comply with fire regulations. Where practicable locks are to be key code or card operated externally and fitted with either a turn snib or handle internally to enable occupants to escape in emergencies Ensuring doors are kept closed and locked to restrict entry Installing an intruder alarm system that meets Australian Standard AS 2201 and incorporates a duress alarm/s to enable staff to activate the alarm in the event of an emergency and

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Restricting access to the pharmacy to authorised staff only and controlling this by: - Fitting single cylinder key, code or card operated dead locks to perimeter doors - Having a restricted keying system fitted to the locks in order to prevent duplication of keys - Strictly regulating the issue of keys, codes or cards at all times, including provision for after hours access - Keeping doors closed and locked to restrict entry - Installing closed circuit television monitors at access doors to screen entry of personnel and record any access to the pharmacy after hours Ensuring, where the risk assessment warrants it, that mobile staff have personal duress alarms.

16. SECURITY IN CAR PARKS:

As part of the facility risk management process, South West Healthcare will ensure, in consultation with staff and key stakeholders that: All reasonably foreseeable security risks associated with car parks are identified, assessed, eliminated where reasonably practicable or effectively controlled The process is appropriately documented Effective car park security procedures are developed and implemented Designated car spaces for afternoon and night shift staff are allocated where practicable and warranted by the risk assessment.

Guidelines:
These procedures have been developed, in consultation with staff and other stakeholders, to effectively manage car park related security risks. The aim of these procedures is to protect people and assets and minimise the likelihood of incidents related to robbery and assault occurring in car parks.

Security Risk Management:

Providing, where practicable, afternoon and night shift staff with designated, controlled parking spaces as close as possible to the facility in a well lit, easily observed area connected to the facility by well lit paths Entry to designated staff parking areas in dual purpose car parks is maintained by clear signage. Staff are accompanied to their cars after hours by the Security Officer. Display of signs in car parks reinforcing theft awareness (eg park smarter, lock it or lose it) Provision of security escorts for staff at the conclusion of afternoon and night shifts. Ensure landscaping is done in a way to provide minimal protection for intruders

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Ensure single and multi storey car parks have: - Good lighting (refer to AS 1158.3.1 ) - Landscaping which leaves the area open and does not intrude on line of sight - As few dark corners and support columns in the design as possible - Flexibility to close some entrances and exits during low traffic periods - Approved locks on exits intended for emergency exit only

Restricting the parking of delivery vehicles to a parking dock Ensuring facility vehicles are parked in a secure overnight car park with good lighting and regular security patrols. A fenced compound or lock-up garage is preferable. Ensuring all facility vehicle keys are held by the designated custodian when the vehicle is not in use, and taken by the driver when the vehicle is required

In addition to control strategies implemented by SWH to reduce risk associated with theft or aggression, staff are be advised to: Comply with security systems established in their local workplace for their protection Use security escort services or travel in groups to the car park when working at night Meet at designated mustering spots where advised to do so Park in well lit areas close to the facility when working at night (if possible, using car spaces located near the workplace specifically allocated to afternoon/night shift workers) or moving the vehicle closer during break Report any suspicious activity Not confront any potential assailants or persons seen attempting to break into a vehicle Not leave valuable or attractive items on view in the vehicle, including small amounts of change scattered in consoles Not load valuable or attractive items into the vehicle in public areas, if the vehicle is to remain parked Not leave important papers, drivers licence or registration papers in vehicles Avoid parking in isolated or dark places and try to park under a street light or in a well lit area. Consider if there will be sufficient light when returning to vehicles after shifts. Activate/use any alarms or other protection devices where they are fitted to the vehicle or car park Close all windows, lock all doors and take the keys when leaving the vehicle Carry keys in hands when approaching vehicle as this will avoid having to stand and search for keys on arrival at vehicle Do not unlock central locking systems or alarm systems until you are close to the vehicle.

17. SECURITY OF PROPERTY:

Contained within this policy.

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18. PROCEDURE IN BREACH OF SECURITY:

ACTION
UNAUTHORISED ENTRY TO PREMISES OR THEFT OF HOSPITAL PROPERTY DETECTED

RESPONSIBILITY

GUIDANCE

REPORT MATTER IMMEDIATELY TO THE SWITCHBOARD OPERATOR

Individual staff member

As per Code Black in Emergency Response Manual

NOTIFY POLICE

Switchboard Operator

All criminal offences must be reported and every assistance provided in pursuing investigations

INVESTIGATE INCIDENT

Department Head, Environmental Safety Manager

COMPLETE INJURY / INCIDENT REPORT FORM

Individual staff member & Department Head

Documentation: MAPPs No. 5.1 Complete Incident Report in Riskman

NOTE: The Hospital maintains a professional security service on the premises from 2130 0700 hours daily. The Security Officer may be contacted by dialling 1323 or paging 542. The Clinical Co-ordinator and Environmental Safety Manager are authorised to employ additional security staff as required. A real time closed circuit TV system monitors access points at Warrnambool campus. Other sites vision only facility for closed circuit TV.

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