General Note
NHS Fife acknowledges and agrees with the importance of a regular and timely review of policy/procedure statements and aims to review policies within the timescales set out.
New policies/procedures will be subject to a review date of no more than one year from the date of first issue.
Reviewed policies/procedures will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.
If a policy/procedure is past its review date then the content will remain extant until such time as the policy/procedure review is complete and the new version published, or there is national policy or legislative changes.
1. FUNCTION
1.1 Key Messages
1.1.1 NHS Fife will as far as is reasonably practicable, follow the principles and practice continued in this policy whilst managing the inspection of NHS premises for the presence of records, other documents or media containing person identifiable information and business documents as part of the decommissioning of premises, including the arrangements for safe transfer, storage of confidential destruction.
1.1.2 Disused buildings should not be used for the storage of any health
records or other person identifiable information.
1.1.3 NHS Fife will ensure that:
• The Director of Property & Asset Management is responsible for co-coordinating the process of inspection of decommissioned buildings.
• The Health Records department and Information Governance Team along with Estates & Facilities Services all play a role in relation to the decommissioning of NHS premises.
• The procedure for checking/auditing of NHS premises is fully recorded.
• Staff involved in decommissioning will ensure safe custody, storage and/or destruction (as appropriate) of any items found.
2. LOCATION
2.1 This policy sets out the framework to oversee the inspection of decommissioned buildings within the Board’s area. Compliance with the policy is mandatory for all Board staff in all locations.
3. RESPONSIBILITY
3.1 The Chief Executive has overall accountability for ensuring that record management including during the decommissioning of buildings operates legally within the Board.
3.2 The Caldicott Guardian will offer advice on any specific issues.
3.3 The Director of Property & Asset Management (or his delegated nominee) will co-ordinate the inspection and will utilise Health Records and Estates & Facilities staff.
3.4 Health Records staff will be the objective “searchers” and recorders of the process.
3.5 Estates staff will ensure the building is safe and facilitate access to normally inaccessible areas eg under plinths, behind radiator covers etc. Estates staff are responsible for decommissioning physical systems on site eg water supply, electricity, alarms and security the premises so far as reasonably practicable. This responsibility includes placing warning signs on site advising against entry to the property and removal of external signage which may facilitate the identification of the premises eg removal of hospital signs at the entrances to sites. Once a building is vacant and secure, regular checks should be made to ensure that the security of the premises has not been compromised with remedial action taken as required to preserve the fabric of the premises pending decisions on eventual disposal or re-use.
3.6 Facilities staff will empty the building and facilitate the search providing access, assisting with the search, removal of waste and its secure disposal.
3.7 All NHS staff should be aware of their personal responsibility to ensure the safety, security and general good management of records. Staff and their Line Managers should be aware of procedures to be followed for the safe transfer and handover of records, documents or media containing person identifiable information when they leave or retire from their post, especially if this coincides with the decommissioning of a building. The procedure should include arrangements for clearing of databases and files containing person identifiable information. Staff are responsible for ensuring records they have created have been dealt with according to NHS Fife policy prior to departure from the organisation.
4. OPERATIONAL SYSTEM
4.1 Process for inspection of NHS premises prior to decommissioning:
4.1.1 In this document the term ‘decommissioning’ has been used to describe any retraction, transfer, closure or change of use of any accommodation, building or premises which are used by NHS Fife.
4.1.2 The process for inspection of premises should be a joint role between Estates, Facilities and Health Records Services and should be led by a Senior Manager who is accountable for the decommissioning process.
4.1.3 Identification of all parties who have an interest in the site or corporate responsibilities for issues relating to the decommissioning process is essential. Those involved, who will form the Decommissioning Team, may include:
• A nominated Site Retraction/Decommissioning Manager
• Facilities Manager who has responsibility for site services
• Estates Manager with knowledge of the site
• IPCT Manager
• Health Records Manager
• Representative of Pharmacy – to advise on all matters relating to medicines and medical gases
• Procurement representative (to advise on the disposal of surplus equipment and furniture etc and to ensure the most cost effective approach is taken to removal arrangements)
• In the case of hospital areas, nursing staff with a working knowledge of the areas would be a valuable additional contributor
4.1.4 A two-stage process should be undertaken to enable absolute clearance of business documents, health records, media or documents containing person identifiable information.
4.2 Stage One – Preparing for retraction:
4.2.1 As appropriate to the size of the site, a team should be assembled to prepare plans for transferring, archiving or destruction of records, documents or media containing business sensitive or person identifiable information. This team should be led by a Senior Manager (Decommissioning Manager) who liaises with the Board’s Records Manager. The Decommissioning Manager should assemble and lead an inspection team to undertake this task.
4.2.2 The Estates Department should prepare an accommodation schedule from up to date copies of building plans. This schedule should list all areas of accommodation contained within the building including any cupboards, basements, attics or areas which have been subject to alteration over the years. Each individual room or area should be listed on the accommodation schedule.
4.2.3 An audit inspection checklist should be drafted to include all areas contained within the accommodation schedule.
4.2.4 Each individual room or area should be physically checked by the inspection team and cross-checked against the accommodation inventory. Any changes or omissions should be entered on to the schedule. Any health records or other documentation containing person identifiable information or business documentation should be noted on the inspection checklist along with details of the responsible department or record holder. Whenever a particular course of action can be identified (eg exceeds minimum retention period – suitable for destruction) then this should also be recorded on the inspection checklist.
4.2.5 The Decommissioning Manager and Records Manager should liaise with the appropriate departments or record holders to agree a course of action and timescale for the transfer, archiving or destruction of the records. The inspection checklist should be updated. The departments or record holders should be asked to notify the Decommissioning/Records Managers when their actions have been completed and the inspection check list updated appropriately. In the event that departments/record holders fail to comply then this should be escalated to the Director responsible for decommissioning to resolve.
4.2.6 Responsible Managers in departments transferring out of accommodation should be advised of procedures for safe transfer, archiving and destruction of health records and documents containing person identifiable information.
4.2.7 As appropriate to the scale of the site, the Decommissioning Manager should table progress reports at relevant operational meetings and progress should be monitored until all actions are complete and the area has been cleared of all records and documentation containing person identifiable information.
4.3 Stage Two – Verification that premises have been cleared:
4.3.1 The Inspection Team is re-assembled when departments have moved out of the accommodation and a further thorough inspection exercise is undertaken to ensure that all business and person identifiable information has been removed. Due diligence is undertaken to ensure that:
• All desks, filing/storage cabinets, drawers, cupboards, and storage shelving have been thoroughly checked. Care is taken to remove drawers and removable fittings to ensure that no business or person identifiable information has been left behind
• Notice boards are checked
• Whenever shelving or racks have been used for records storage these should be dismantled to ensure that no business or person identifiable information has slipped under, behind or between shelves
• Where accommodation contains attic or basement areas or has been altered from plans to conceal areas, arrangements should be made via the Estates Department to have these areas accessed and inspected, including taking photographic images as proof of clearance if the areas are inaccessible by the Inspection Team
• Whenever areas cannot be completely accessed eg locked areas or areas where shelving units require to be dismantled then these should be noted on the checklist and the Inspection Team should return to inspect the area
• Each individual room and area should be photographed using a digital camera which dates and times the image as proof that the area was cleared
• Particular attention should be paid to any notices or signs left within the premises which may contain patient identifiable information. Examples might include fire evacuation registers, patient diet sheets, and patient names written on white boards
• All desks, filing/storage cabinets, drawers, cupboards, and storage shelving must be thoroughly checked prior to removal from site
• Any sealed envelopes found should be opened
• Care must be taken to remove drawers and removable fittings to ensure that no business or person identifiable information has been left behind at the back of drawers or behind cabinets
• No cupboards, filing cabinets or drawers should be removed if they are locked until access has been obtained to view the inside of the unit. If keys cannot be located, Estates/Facilities must be asked to force units open
4.3.2 Each area should be labelled with a self adhesive notice:
Inspection Date:
This area has been cleared of all NHS Board records and documentation. Under no circumstances should any records or documentation be stored in this room. If you require further Information then please contact the Head of Estates or Health Records Manager.
4.3.3 Any records or documents found containing business or person identifiable information should be bagged, labelled with the room number/description and location and removed from the decommissioned area to a secure area for further action by the Records Manager or other designated officer. The appropriate individual should be contacted to remove any IT equipment or media.
4.3.4 The inspection checklist should be updated to advise whether the area is clear, whether records, documentation or media have been removed for safekeeping, archiving or destruction along with the action taken eg relocated to, destroyed etc, or the area requires to be revisited.
4.3.5 When all records, documents or media containing business or person identifiable information have been safely removed the checklist should be signed off by the Inspection Team and countersigned by the Director who is accountable for the decommissioning process. Where practicable, removal of any patient identifiable information should be undertaken as the inspection proceeds. If this is not practical a clear note should be made of items requiring subsequent attention with agreed timescales.
4.3.6 Records, documents and media removed by the Inspection Team should be dealt with in accordance with the most up-to-date guidance.
4.3.7 At this point access to the area or building should be restricted to designated personnel through the Decommissioning Manager.
4.4 Following Vacation:
4.4.1 Following full vacation of a building or complex, responsibility for future security of the site transfers to the Director of Property & Asset Management who shall be obliged to advise the Chief Executive and the designated Director or General Manager of any incidents on site. The date on which responsibility transfers shall be documented in writing.
5. RELATED DOCUMENTS/REFERENCES
Glossary
Person identifiable information includes:
• Name, address, postcode, date of birth.
• Pictures, photographs, video tapes, audio tapes or other images of patients, clients and staff.
• CHI number and local patient/person identifiable numbers.
• Anything else that may be used to identify a person directly or indirectly (eg rare diseases, drug treatments or statistical analyses which have very small numbers within a small population may allow individuals to be identified).
