Standard Operating Procedure 1 (SOP 1)

Safe Management, Security and Control of Keys,

Digital Locks and Swipe Access Control Devices
Why we have a procedure?
To purpose of this Keys, Digital Lock and Swipe Card Access Control Standing
Operating Procedure (SOP) is to describe the Trust operational procedures for the safe
management and control of all access devices within Trust premises.

All access control swipe card devices and keys etc. as described in this SOP are the
sole property of The Trust and shall not be altered, duplicated or transferred or loaned
to unauthorised individuals. Disciplinary action in line with the Trust Disciplinary Policy
may be taken against individuals who fail to contravene this security requirement.

What overarching policy the procedure links to?

Electronic Access Door Control Policy

Which services of the trust does this apply to? Where is it in operation?

Group Inpatients Community Locations

Mental Health Services   all
Learning Disabilities Services   all
Children and Young People Services   all

Who does the procedure apply to?

 Heads of Departments
 Ward Managers
 Reception staff
 All employees, including Bank and Agency staff

When should the procedure be applied

 At the start of all shift changes and handover within inpatient services
 When keys or other access devices are controlled by Reception areas
 The safe keeping and issuing of keys within any department or ward

How to carry out this procedure

All Keys, digital locks and access control devices shall be at all times secured and
managed so far as to prevent loss, theft, misuse and from accidentally being removed
from the premises.

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Access Control Swipe Cards

Authorisation of ID Access Cards

 Managers are responsible for ensuring that their area of responsibility is risk
assessed and that they fully understand the access and egress requirements of
their area
 Managers will assume the role of Departmental Named Authoriser, or appoint a
member of staff to carry out this duty as well as, or on their behalf
 Managers are responsible for authorising staff to access their area through the
electronic control system by completing the ID badge application form (Appendix
2 of the Electronic Door Access Control Policy) specifying access levels
required
 Managers are expected to encourage and support staff to challenge anyone who
they do not recognise who attempts to follow them into a restricted access area
 All employees are responsible for safe keeping of their access control devices
 Managers and staff must ensure that any lost or damaged badges are reported to
the Estates Helpdesk

Cancellation of ID Access Control Cards

 Managers of staff are responsible for the security and returning of access cards
back to the helpdesk within one week of an employee leaving the Trust
 All staff listed as leavers will have their ID badge disabled by the Helpdesk within
one week of termination of employment and/or immediately where security access
is no longer required

Security and Control and Issuing of Keys and Access Fobs (Wards)
Keys and security access fobs are provided within inpatient services. Managers of
these services will ensure that the following actions and procedures are in place:
 That all fobs and keys are tagged and serialised
 That a daily signing in/ out procedure is in place at the start and end of all shift
changes to ensure keys and fobs are accounted for (see Appendix 1 Signing in/
out log sheet)
 That the ward manager at the start of each /and end of shift physically accounts
for all access keys, fobs devices ensuring that they are signed in/out
 That a monthly audit is undertaken and documented to ensure that signing in/out
procedures are effective and are being followed
 That keys and fobs that are unaccounted for are reported to the line manager,
reported on Datix and reported to the issuer/ provider for deactivation
 Any access item found to be deficient during handover is to investigated and
reported on DATIX
 Under no circumstances should security keys/access fobs or swipe cards be
removed from any ward or Trust premises

Reception Staff (Issuing Security and Control and Issuing of Keys and Access
Fobs)
All reception staff responsible for the safe management and issuing of keys will ensure
the following:
 That all keys and access devices are securely maintained within their department
 That no security access is left unattended
 That any IT equipment used in the development of ID cards is password protected
and that the systems is switched off when not in use
 That they maintain a signing in/ out register of all keys/ fobs or security access
devices
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 That they immediately report to the Estates Helpdesk any losses or failure to
return access devices so that the device can be deactivated
 That the manager of reception undertakes a monthly audit and physical check of
keys against the register and challenge any discrepancies
 Ensuring access control device into a ward environment is only issued to staff
employed to work on a ward

Digital Door Locks

Digital door locks are provided throughout Trust premises and where these are fitted
the following procedures must be adhered to:
 The code must be changed every 12 months or sooner depending on the
circumstances
 The code must not be written down and displayed regardless of the
circumstances
 Where digital locks are in use they must remain operational and left in the unlock
position
 The LSMS will review the appropriateness of digital locks across Trust premises
 All damaged locks should be reported to the helpdesk to ensure an early
response to unsecured areas

Monitoring and Auditing of Keys and Access Control Device (All Departments)
All managers responsible for the safe management and control access devices keys,
fobs etc. and will complete a monthly check using the form at Appendix 2 and report
and investigate any deficiencies.

The Local Security Management Specialist during security inspections will audit this
requirement and address any concerns with the manager.

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Appendix 1: Department Key/ Security Device Signing in/ out (all security access control devices including keys must be signed for)

Date Time out Print Name Key/device Sign out Sign in Time in
No

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Appendix 2: Managers Monthly Check of Keys and Access Control Devices

Date Time This is to certify that I have Signature The following issues Recommended Date
completed a monthly check of were identified action completed
all key and access devices
(Print Name)

Re-print copies as required

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Where do I go for further advice or information?
Further information and advice is available from the following personnel:
 Head of Health Safety Fire Security
 The Local Security Management Specialist
 The Health and Safety Team
 Estates Helpdesk

Policy Links
 Security Management Policy
 Occupational Health and Safety Policy
 Risk Management Policy
 Disciplinary Policy and Procedures

Roles and Responsibilities

The roles and responsibilities are contained within the overarching policy

Training
No Training requirements in relation to this procedure

Monitoring / Review of this Procedure

In the event of planned change in the process(es) described within this document or an
incident involving the described process(es) within the review cycle, this SOP will be
reviewed and revised as necessary to maintain its accuracy and effectiveness.

Equality Impact Assessment

Please refer to overarching policy

Data Protection Act and Freedom of Information Act

Please refer to overarching policy

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 Standard Operating Procedure Details
Unique Identifier for this SOP is BCPFT-SEC-SOP-02-1

State if SOP is New or Revised New

Policy Category Health and Safety

Executive Director
Director of Nursing
whose portfolio this SOP comes under
Policy Lead/Author
Head of Health and Safety
Job titles only
Committee/Group Responsible for
Health and Safety Committee
Approval of this SOP
Month/year consultation process
December 2016
completed
Month/year SOP was approved December 2016

Next review due December 2019

‘B’ can be disclosed to patients and the
Disclosure Status
public

Review and Amendment History

Version Date Description of Change
Dec New SOP for BCPFT to support Electronic Access Door Control
1.0
2016 Policy

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