CG Reference Document No 21 L PROTOCOL FOR USE AND UPKEEP OF ALARM SYSTEM IN KYLEPARK ASSESSMENT & TREATMENT CENTRE, KIRKLANDS Version 3 March 2017 Any changes made from previous version are highlighted throughout the document in GREY Any changes made from previous version are highlighted throughout the document in GREY Next Review Date: 30/03/2020 Review Date: March2020 Version No 2 Author: P Brown Implementation Date: October 2011 Original Document Prepared by: P.Brown
INDEX CONTENT Page No Alarm system equipment 3 Storage of fobs and pagers 3 Activation of the alarm system 3 Resetting the alarm 3-4 Reading / clearing entries on the pager 4 Inpatient facility 4 Outpatient facility 5 Response to alarm activation Meeting / interview room Disabled toilet Therapy rooms 5 5 5-6 Maintenance 6 Health & Safety 6 Appendices Test recording sheet for alarm system Test recording sheet for alarm system outpatient facility Induction sheet for use of alarm system Recording sheet for use of alarm activators / pagers in-patient facility Recording sheet for use of alarm activators / pagers out-patient facility 7 8 9 10 11 Reference of Names of Programmed on Pagers 12 NHSL ALDS Protocol for Use and Upkeep of Alarms Systems in Kylepark A&T Centre V2 February 2013 2
The alarm system comprises of: - KYLEPARK ASSESSMENT & TREATMENT CENTRE, KIRKLANDS OPERATIONAL PROTOCOL FOR ALARM SYSTEM Alarm Activators (red & blue fobs) There are two different styles of red alarm fobs: i) Droplet appearance that can only be charged by the appropriate adaptor ii) Rectangle shape that is battery operated. [Both these fobs are similar in that they can be activated by the red button or by pulling the bottom pin out.] Nurse assistance call pads situated at: i) Reception ii) Visitors Disabled Toilet iii) Nurses Hub iv) Clinical Exam v) Day Dinning Rooms 1-4 vi) Overnight toilet Pagers Three control panels. These are strategically situated throughout Kylepark centre i) Nurses hub (panel one) ii) Staff Rest Room (panel two) iii) Reception (panel three) Every room / area within the Assessment & Treatment Centre has a sensor, with the exception of Disabled toilets, Visitors Lounge, Regen Kitchen, Sluice, Dirty Linen room and Staff Facilities. The four courtyards have two external orange sensors including the reception garden area. Every Fire door / exit is linked to the nurse alarm system. Control box, to reset the alarm is situated within the Nurses hub STORAGE OF FOBS / PAGERS 1. All pagers for use within the inpatient facility will be stored safely within the Nurses Hub, and will only be distributed by the Nurse in Charge. 2. All members of Kylepark nursing team are allocated their own personal fob, which they are responsible for ensuring the safe keeping off. The Assessment Unit Manager will keep a register of the unique identification code for each fob allocated to staff. 3. The Nurse in Charge of the duty shift will be responsible for signing in / out of activators to bank or agency nurses during their duty shift. 4. All fobs for use within the outpatient facility will be stored safely within the Reception Area, and will only be distributed by the Receptionist. ACTIVATION OF THE ALARM SYSTEM The alarm can be activated by: pressing the red button on the fob pulling the bottom cord on the fob pressing the two side buttons simultaneously (droplet fob only) pulling the cord in the disabled toilets pressing the large red button on the nurse assistance pads opening a fire door prior if the door alarm has not been switched of manually by a key NHSL ALDS Protocol for Use and Upkeep of Alarms Systems in Kylepark A&T Centre V2 February 2013 3
Pointing the alarm fob directly at the orange box in the external areas and pressing the red button. RESETING THE ALARMS The alarm can be reset by: using the blue fob at the activated sensor. (NB ensure the bottom cord on the fob has be pushed back in if this is how the alarm has been activated). pressing the blue button TWICE on the nurse assistance pad, if the pull cord or orange button has been activated. The fire door can be reset by turning the key switch off then back to on, then repeated with a further switch to off then back on. The light will initially flash green then go off. Ensure the door is closed when resetting the door alarm. By pressing the blue button on the control box in the duty room. This may only be carried out by the Nurse in Charge when they are certain the situation has been resolved. READING / CLEARING ENTRIES ON THE PAGER Normally the pager will display ++ and when it receives a call it will bleep and display a message. To stop the pager bleeping press the bottom button. To clear the entry on the pager press the second button, this will display all the areas in which the alarm was activated, press again which will state delete, press the second button again to clear the entry. Keeping do so until all entries are cleared and the display resumes to ++. Do not clear the pager until the incident has been resolved. INPATIENT FACILITY 1. All staff on duty including domestic services will be in possession of an alarm activator in the form of a small unobtrusive key ring. 2. Three staff per shift will be identified as page holders and these will be identified within the Daily Duty Allocation. The member of staff supporting the individuals within the Low Secure Facility will not be a page holder. 3. If the page holder requires to leave the premises at any point during their shift the nurse in charge will be responsible for identifying another member of staff 4. New members of the nursing team will be informed of the protocols in use for the alarm system and will undergo induction prior to commencement of duty and allocation of an alarm activator. On completion of induction will sign appendix 2. 5. All visiting staff will be greeted by the Nurse in Charge and directed to the Nurses Hub on entering the inpatient facility. 6. All visiting staff in attendance at the in-patient facility will be issued with an alarm activator when one to one contacts with a patient is necessary either within the in-patient or out-patient environments. If there is more than one visiting member of staff to see a patient only one fob will be provided to the staff member taking the lead in the visit. The fob will require to be signed in/ out on appendix 3. 7. If a member of staff requires to activate the pager in the courtyard it is always advisable that they do so by pulling the bottom cord on the fob. 8. It is the responsibility of the Assessment Centre Manager to ensure that all nursing staff are up to date with PAMOVA training. NHSL ALDS Protocol for Use and Upkeep of Alarms Systems in Kylepark A&T Centre V2 February 2013 4
9. Nursing staff should respond to each incident as per devised risk assessment and appropriately utilising the PRN protocol, if required. Additional support / advice can be sought from the Consultant Psychiatrist or on call, Kylepark Centre Manager or On Call Service Manager. Or Police if required. OUTPATIENT FACILITY 1. Any member of staff from the Adult Learning Disability Service who is interviewing a community patient within the Outpatient area will require to bring their NHS mobile phone and provide the administration staff with a note of their mobile phone number when they sign out a fob, swipe card and key. 2. Prior to staff utilising the alarm system staff must ensure their mobile phone has adequate reception within the interview / meeting rooms and have been informed by the Centre Manager of the protocols in use for the alarm system and will undergo induction prior to allocation of an alarm activator. On completion of induction will sign appendix 2. 3. Staff must ensure the room they are using has all additional unnecessary items removed and stored safely to minimise risks. Including giving assurances their mobile phone is quickly accessible and they have gave consideration to where they position themselves within the room to allow a quick exit if required. 4. The interview rooms must not have any pictures, clocks or posters on the walls. Anyone putting items on the wall for training purposes, etc must remove them directly after use. (NB only using white tac to attach them to the wall) 5. It is the responsibility of each Head of Dept to ensure that staff is up to date with PAMOVA training. RESPONSE TO ALARM ACTIVATION IN OUTPATIENT FACILITY (INTERVIEW / MEETING ROOM) 1. It is the responsibility of administration staff within the reception area to respond if the alarm is activated within the Visitors Disabled Toilet, Interview & Reception Fire Exit, Meeting or Interview Rooms. 2. On hearing the alarm staff will check to see where the alarm has been activated. 3. If accidental activation occurs the person responsible must immediately advise the administration staff who will in turn advise Kylepark nursing staff of the false alarm; then take the blue fob with them to cancel the alarm. 4. If they have not been advised that a false alarm has occurred the administrative staff will call the person in the room on their mobile phone to enquire if they need assistance. 4.1 If the mobile phone is not answered the administrative staff will immediately call 999 requesting Police assistance and relay this information to the nursing staff who have responded to the activated alarm 4.2. Nursing staff will go to the room, look through the observation panel or ask at the door if assistance is required. The person within the room will be supported to leave the room, if they have not already done so. 4.3 Staff will help either keep the area clear or enable the colleague within the room to exit the area. Only when safe or practical to do so the alarm will be silenced by the administrator using the blue fob. RESPONSE TO ALARM ACTIVATION IN OUTPATIENT FACILITY (DISABLED TOILET) 1. If the alarm is activated the administration staff will take the blue fob and an access key with them and go to the toilet and shout to the person in the toilet if they need assistance. 2. If the person requires assistance the administrative staff will pull the cord on the blue fob to alert nursing staff assistance is required. Access can be gained utilising the key the administrative staff will have provided. 3. If the person in the toilet has accidentally set of the alarm the administrative staff will alert Kylepark nursing staff that it is a false alarm and request the person within the toilet presses the blue button twice or wait until they have evacuated the toilet area if they are unable to undertake this task. NHSL ALDS Protocol for Use and Upkeep of Alarms Systems in Kylepark A&T Centre V2 February 2013 5
RESPONSE TO ALARM ACTIVATION IN OUTPATIENT FACILITY (THERAPY ROOMS) Or 1. Staff using the Therapy rooms / gym should consider the potential risks that may be posed by community patients and devise an appropriate risk assessment that will provide guidance on how to minimise risks whilst utilising these rooms i.e. considering if two staff from the department should be present. 2. It is the responsibility of nursing staff to respond if the alarm is activated within the therapy rooms. 3. The duty allocation sheet will identify the nurse responsible for responding if the alarm is activated within these rooms. 4. On going to the room knock the door, enter, and on opening the door ask if assistance is required. The person within the room will be supported to leave the room, if they have not already done so. 4.1 If assistance is required the nursing staff will ask administrative staff at the Reception Desk to request Police assistance. 4.2 Staff will help either keep the area clear or enable the colleague within the room to exit the area. 4.3 Only when safe or practical to do so the alarm will be silenced by the nurse using the blue fob. 5. If false alarm then nursing staff will reset the alarm. MAINTENANCE 1. A weekly alarm test will be carried out by a designated other on duty every Saturday at 8am to ensure no faults are present within the system and to easy access within the Out-patient facility. Faults in the system will be reported to PSSD, Hotline Repairs at Monklands Hospital. 2. This will be recorded and monitored on a recording sheet and signed by the designated nurse completing the test. The completed form will be submitted to the Assessment Centre Manager. 3. Tests will be completed on a rotational basis. (see appendix 1). 4. The receptionist will carry out a weekly test on the alarm fobs used within the Outpatient facility (see appendix 1a). 5. The receptionist will ensure the fobs within the Outpatient facility are fully charged and nursing staff will ensure each Thursday when carrying out the weekly test that the inpatient fobs are fully charged. Both the inpatient and outpatient facility will have one charger each. A green light will be evident for a fully charged fob by pressing the green button on the fob. The fob will require recharging when the LED is amber or red. When red a warning will sound by giving an intermittent beep. A fully charge battery will last about 6months depending on use. To fully charge a fob will take approximately 1 ½ hrs. 6. The Pagers are battery operated. The battery is place in the bottom of the pager by pressing the cap down, sliding to the side and enabling the hinge to release the cap. Replacement batteries will be ordered via PECOS. HEALTH & SAFETY All staff accessing facilities within Kylepark will undergo induction as to the operational use of the alarm system and be informed of all protocols for the use and upkeep of the alarm system (See appendix 2) All nursing and domestic staff on duty will carry an alarm activator. All visiting staff will be aware of the operational procedures prior to being issued with an alarm activator. A record of staff/visitor induction will be maintained and updated where necessary. All visiting staff will complete the recording sheet for use of alarm activators. All incidents of the alarm being activated must be recorded on a DATIX by the person setting off the alarm with the exception of the incidents whereby the alarm was accidentally activated. When a patient has activated the alarm the person attending to the incident will be responsible for completing the DATIX. NHSL ALDS Protocol for Use and Upkeep of Alarms Systems in Kylepark A&T Centre V2 February 2013 6
LANARKSHIRE ADULT LEARNING DISABILITIES SERVICE APPENDIX 1 KYLEPARK ASSESSMENT & TREATMENT CENTRE, KIRKLANDS TEST RECORDING SHEET FOR ALARM SYSTEM Date:. Name of Nurse completing the test: Control Panel No: 1 * / 2 * (delete as appropriate) Fob No Present In good working order Action Fob No Present In good working order Action Pager No Present In good working order Action Week 1 Week 2 Week 3 Sensor / Alert Activated In good working order PSSD Job No. Sensor / Alert Activated In good working order PSSD Job No. Sensor / Alert Activated In good working order PSSD Job No. Cloister Courtyard 1 ( x2) Overnight toilet (pad) Reception area (x4) Day Rm 1 (sensor & pad) Day Rm 3 (sensor & pad) Reception (pad) Single room 1 Courtyard 3 (x2) Corr Interview Ensuite 1 Bathroom 3 Rec gdn Single room 2 Single room 7 Meeting Room Ensuite 2 Ensuite 7 Interview Room 1 Single room 3 Sinlge room 8 Interview Room 2 Ensuite 3 Ensuite 8 Interview Room 3 Corr 1 (x2) Single room 9 Interview Room 4 Care Co-ordinators hub Ensuite 9 (sensor & pad) Visitors Disabled Toilet Hub area (x 4) Corr 3 (x2) Corr Therapy 1 (x2) Assessment Manager Bathroom 4 Therapy Room 1 Disabled toilet (pad & cord) Day Rm 4 (sensor & pad) Therapy Room 2 Day Rm 2 Courtyard 4 (x2) (sensor & pad) Courtyard 2 ( x2) Single room 10 ADL Kitchen Single room 4 Ensuite 10 Sensory Integration Room Ensuite 4 Single room 11 Gymnasium Single room 5 Ensuite 11 Corr Therapy 2 (x2) Ensuite 5 Single room 12 Corr Link (x Single room 6 Ensuite 12 Corr Service (x Ensuite 6 Corr 4 Corr 2 (x2) Clinical Exam NHSL ALDS Protocol for Use and Upkeep of Alarms Systems in Kylepark A&T Centre V2 February 2013 7
LANARKSHIRE ADULT LEARNING DISABILITIES SERVICE KYLEPARK ASSESSMENT & TREATMENT CENTRE, KIRKLANDS APPENDIX 1 a TEST RECORDING SHEET FOR ALARM SYSTEM OUTPATIENT FACILITY Date:. Name of Person completing the test: Control Panel No: 3 Weekly test on a Thursday morning (9am) to be completed on the outpatient fobs by the Receptionist Receptionist to advise the Nurse in Charge in the inpatient facility that a test is being carried and when the test is completed. Receptionist to report any faulty fobs or issues with the control panel to PSSD Completed form to be given to the Assessment Unit Manger, who will retain the form within the Health & Safety Appendix folder. Fob No Present In good working order Action NHSL ALDS Protocol for Use and Upkeep of Alarms Systems in Kylepark A&T Centre V2 February 2013 8
LANARKSHIRE ADULT LEARNING DISABILITIES SERVICE KYLEPARK ASSESSMENT & TREATMENT CENTRE, KIRKLANDS APPENDIX 2 INDUCTION SHEET FOR USE OF ALARM SYSTEM DATE NAME SIGNATURE INDUCTION COMPLETED BY SIGNATURE NHSL ALDS Protocol for Use and Upkeep of Alarms Systems in Kylepark A&T Centre V2 February 2013 9
LANARKSHIRE ADULT LEARNING DISABILITIES SERVICE KIRKLANDS HOSPITAL KYLEPARK ASSESSMENT & TREATMENT CENTRE APPENDIX 3 RECORDING SHEET FOR USE OF ALARM ACTIVATORS / PAGERS In-patient facility DATE NAME ACTIVATOR NO. PAGER NO. SIGN OUT SIGN IN COMMENTS (e.g. faults, damage, loss etc) ACTION TAKEN Note: It is the responsibility of the NURSE IN CHARGE to issue alarm systems at the start of each duty. HEALTH & SAFETY (please note) It is the responsibility of every individual to ensure that the personal activator / pager is operational and carried at all times while on duty. Anyone not following these instructions do so at their own risk NHSL ALDS Protocol for Use and Upkeep of Alarms Systems in Kylepark A&T Centre V2 February 2013 10
LANARKSHIRE ADULT LEARNING DISABILITIES SERVICE KIRKLANDS HOSPITAL KYLEPARK ASSESSMENT & TREATMENT CENTRE APPENDIX 3 a RECORDING SHEET FOR USE OF ALARM ACTIVATORS / PAGERS Out-patient facility DATE NAME ACTIVATOR NO. MOBILE PHONE NO. SIGN OUT SIGN IN COMMENTS (e.g. faults, damage, loss etc) ACTION TAKEN Note: It is the responsibility of the RECEPTIONIST to issue alarm systems at the start of each duty. HEALTH & SAFETY (please note) It is the responsibility of every individual to ensure that the personal activator is operational (i.e. press the green button to check the light is green or amber) Anyone not following these instructions do so at their own risk NHSL ALDS Protocol for Use and Upkeep of Alarms Systems in Kylepark A&T Centre V2 February 2013 11
Reference of Names of Programmed on Pagers Cloister Corr Interview Rec Gdn The area between reception and the inpatient area Refers to the corridor outside the meeting and interview rooms The grassy area between reception and wing 4 bedrooms Corr Therapy 1 The corridor commencing from visitors room to Therapy Room 2 Corr Therapy 2 Corr Service Day Rm 1-4 Corr 1-4 Hub area The corridor commencing from ADL kitchen, leading out to the fire door and the small corridor across from the gym. The corridor outside the regen kitchen, staff facilities. Each day dinning room, whether sensor or nurse call pad is activated Corridor along each wing The area directly outside the Nurses hub Bathroom 3-4 Assisted bathrooms in wing 3 or 4 Fire Exit Interview Fire Exit Therapy Fire Exit Service Fire Exit 2-4 The fire door outside the meeting and interview rooms The fire door along from the gym The fire door next to the staff rest room The fire door off each wing in the inpatient facility NHSL ALDS Protocol for Use and Upkeep of Alarms Systems in Kylepark A&T Centre V2 February 2013 12