Management of Patients’ Valuables & Property Policy · Patient Valuables, ... Guardian before...

Management of Patients’ Valuables & Property Policy

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Reference number WHHT: F006

Version 3

Author Name & Job Title Wendy Joy, Patient Services Manager

Executive Lead Tracy Carter, Chief Nurse

Approved by/ Date Health and Safety Panel / 22nd March 2018

Ratified by Quality & Safety Group

Date ratified 18th April 2018

Committee/individual responsible

Health & Safety Panel

Issue date April 2018

Review date April 2021

Target audience All WHHT Staff

Additional Search Terms (Key Words)

Patient Valuables, Patient Property

Previous Policy Name Management of Patients’ Valuables & Property Policy

Ref: WHHT: F006

Author: Wendy Joy

Date: April 2018

Review Date: April 2021

Version no: 3

of 18

CONTRIBUTION LIST

Key individuals involved in developing this version of the document

Name Designation Wendy Joy Patient Services Manager

Amanda Clark Health Safety and Fire Manager

Karen Moore Head of Security and Safety Management

Approved by Group/ Committee Health & Safety Panel / March 2018

Ratified by Group/Committee Quality & Safety Group / April 2018

Change History

Version Date Author Reason for change

2 April 2015 Wendy Joy Review and update

3 February 2018 Wendy Joy Review and update

Ref: WHHT: F006

Author: Wendy Joy

Date: April 2018


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CONTENTS

1 Aim ....................................................................................................................... 4

2 Objectives ............................................................................................................ 4

3 Definitions ............................................................................................................ 4

4 Scope ................................................................................................................... 4

4.1 Adults ............................................................................................................ 4

4.2 Minors and Patients Lacking Capacity .......................................................... 5

5 Responsibilities .................................................................................................... 5

6 Procedure ............................................................................................................. 6

6.1 General Process/Admission .......................................................................... 6

6.2 Discharge or Internal Transfers ..................................................................... 8

6.3 Death of the Patient ...................................................................................... 8

6.4 Patient Property Taken into Safe Keeping .................................................... 9

6.5 Transfer of Property/Valuables During Office/Out of Office Hours .............. 10

6.6 Special Circumstances ................................................................................ 10

6.7 Missing Property/Property Claims ............................................................... 11

6.8 Documentation/Transparent Valuable Bags ................................................ 11

6.9 Missing/Left Behind and Lost Property ........................................................ 12

7 Evaluation measures .......................................................................................... 12

7.1 Monitoring ................................................................................................... 12

7.2 Audit & Review ............................................................................................ 13

8 Equality Impact Assessment Statement ............................................................. 13

9 References ......................................................................................................... 13

10 Related Policies.................................................................................................. 16

11 Equality Impact Assessment .............................................................................. 17

12 Policy and Procedure Sign-off Sheet .................................................................. 18

Ref: WHHT: F006

Author: Wendy Joy

Date: April 2018


Version no: 3

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1 Aim

This policy explains what to do with patients' property, both of a valuable and non-valuable nature. It will be of interest to all staff involved with the management of patient property within WHHT and is designed to clarify the requirements of all staff who manage the property of patients as part of their work within the Trust and in relation to admission to wards and departments, transfer or discharge to other health care organisations or non-health care organisations/home. The principle concern of the WHHT is to ensure the safe keeping of patients’ property entrusted to them by the patient.

2 Objectives

The purpose of this policy is to ensure safe and secure management of property belonging to a patient or client and to minimise the risk to the patient and Trust of loss and/or damage. The objectives are:

To clarify the accountability of the health care professionals who are responsible for the patient’s property while under their care

To ensure that there are safe and appropriate procedures in place to manage patient’s property

To provide key procedures and processes to ensure the safekeeping of Patient property

3 Definitions

Patients’ property can be broadly classified into four types:

Essential Personal Items: Hearing aids, spectacles, dentures, walking stick

Valuables: including monies or cash equivalent property, credit cards, cheque books, bank books, social security benefit books, jewellery, electronic goods etc.

Clothing: including, shoes, suitcases & handbags

Other items; for example offensive weapons, medicines, alcohol or illegal substances should be reported immediately to a senior member of staff on the ward or department to establish the risk and decide the most appropriate course of action. Dependant on risk staff will need to complete a risk assessment.

4 Scope This policy applies to all services directly provided by the organisation and covers the management of patient’s property, both valuable and non-valuables. WHHT will expect other services that use the organisation to also apply the principles of this policy as a minimum standard within their service.

Ref: WHHT: F006

Author: Wendy Joy

Date: April 2018


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4.1 Adults

The policy applies to individuals, over the age of 16 accessing healthcare services and facilities within the organisation.

4.2 Minors and Patients Lacking Capacity

With respect to minors, or patients/clients who lack mental capacity, it will apply to those identified as having the guardianship or legal power e.g. Power of Attorney. Please note Power of Attorney must be checked with the Office of the Public Guardian before handing over property of value.

5 Responsibilities

It is the duty of the WHHT executive team to make staff aware of this policy and for providing the necessary resources to ensure its correct application. The Chief Executive has ultimate accountability for ensuring the provision of high quality, safe and effective care within WHHT.

It is the duty of the admitting nurse to advise patients to send property home whenever possible with relatives or others and to ensure a disclaimer form is completed and signed if valuables are to be kept by the Patient.

The Nurse in Charge of the ward area is responsible for ensuring that the Patient Property Form and Disclaimers are completed on the admission of the patient.

Senior nursing and managerial staff have a responsibility to ensure that all staff are aware of and adhere to this policy. They are also responsible for ensuring that any deviation or errors arising are dealt with in the correct manner, using Datix, and that risks are identified, recorded and acted upon.

All staff employed by WHHT– clinical and non-clinical are responsible for applying the principles contained within this policy

All staff have a responsibility to know the location of property taken into safekeeping and ensure that this is recorded and communicated to other health care professionals throughout the patients stay

Where the reason for any loss of valuables cannot be immediately identified, this should be referred first to the senior nurse in charge and an internal investigation must be carried out and documented. Details of this investigation must be entered on the Trusts Datix system.

As a principle it is the patient’s responsibility to ensure the storage and safe keeping of their property unless it is handed over for safekeeping

The principle concern of the organisation is the demonstration of safe practice when managing patient property within WHHT

It must be assumed that patients have the mental capacity for the management and safekeeping of their property, if there is concern and the patient is not accompanied their valuables must be recorded in the property book then taken immediately to Patient Affairs, if out of hours secured and placed in one of the trusts drop and night safes.

Ref: WHHT: F006

Author: Wendy Joy

Date: April 2018


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6 Procedure

6.1 General Process including Admission

1. Every ward/department must display a Trust standard disclaimer notice relating to patients’ property.

2. The disclaimer form and the wording within should be brought to the attention of the patient. If the patient is unconscious on arrival, the notice must be brought to their attention as soon as they are conscious. A record of the date when the notice is brought to the attention of the patient should be recorded

3. If the Trust fails to obtain a signed disclaimer and the property remains with the patient, the Organisation could be liable for loss, due to negligence.

4. It must be assumed that all patients have the capacity to make a decision about the safekeeping of their property; if it is deemed that a patient does not have the mental capacity to make that decision staff must follow the procedures within this policy and ensure valuables are placed under safekeeping.

5. Property must follow the patient and, on transfer, the property book updated with new ward details and any changes to property being held on the ward.

6. The description of the articles should be factual and related to the appearance of the article, not what they are assumed to be. Use of terms such as ‘gold’ and ‘silver’ must not be used when describing items of jewellery. Descriptions such as ‘yellow coloured metal’ or ‘white coloured metal’ must be used instead. Stones in rings or other jewellery must not be described as ‘diamond’, ‘ruby’ etc. but the terms ‘white coloured stone’, ‘red coloured stone’, must be used.

7. Only two property books should be in use at any one time in an area. These items should be treated as controlled stationery.

8. If patients are unable to look after their property due to illness or lack of capacity for any reason, money, valuables and house keys should be retained by the Trust until patients have recovered sufficiently to give instructions as to their safe-keeping.

9. If patient’s property is returned to a relative or carer at any time during the patient’s stay within the hospital, the property book needs to be signed by the patient to confirm receipt of the property returned. This will make it clear what has been returned minimising disputes at a later stage and must be obtained and stored in patient’s notes. This is especially in relation to money, jewellery and other valuables, dentures, hearing aids or other similar medical devices. (See Section 6.3 below for information regarding returning patient property to a relative/carer when it is not possible to obtain consent.)

10. Any concerns about the safety of patient’s electrical equipment should be submitted for testing by Estates and Facilities before it can be used on Trust property.

6.1 Admission

1. Patients called for elective admission and day surgery will receive information in advance during which they will be advised not to bring valuables into hospital. In the event they have to do so, they are informed that no responsibility can be accepted by

Ref: WHHT: F006

Author: Wendy Joy

Date: April 2018


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the hospital if valuables are not placed for safe keeping with the nurse in charge of the ward. With essential personal items such as hearing aids and spectacles, we recommend patients bring cases or containers with their name and contact telephone number clearly marked.

2. Patients should be advised prior to admission to bring only minimum amounts of property and valuables into hospital.

3. Where this has not been possible, e.g. in the case of emergency admission, patients should be advised to have valuables taken home as soon as possible. This must be reinforced at the time of admission.

4. Where this is not possible patients should be advised to deposit any money or valuables which are not immediately required into the Patients Affairs office or the night safe for safekeeping.

5. Patients’ Personal Item – Normally it is the responsibility of the patient to take care of their own dentures, spectacles and or hearing aids. If the patient is unable to accept this responsibility, for example if confused or unconscious, this should be recorded on the Property Book. In these circumstances dentures, spectacles and or hearing aids must be stored in a jiffy type envelope or transparent receptacle, labelled and locked away.

6. If the patient declines to hand over their valuables and a disclaimer is signed and obtained, the Trust cannot accept liability for any loss incurred. Where a patient refuses to sign a disclaimer this must be noted on the disclaimer form and property book by the staff and signed by two members of staff. This should also be brought to the attention of the ward manager.

7. Where valuables are held at ward level this must be for the shortest possible period of time and no longer than 24 hours or until the morning of the next working day. No valuables should be retained at anytime on ward level, they should be deposited into the Patient Affairs Office or night safe.

8. Where property/valuables are being held by Patient Affairs Office, ward staff must inform Patient Affairs when a patient is being transferred between wards or discharged.

9. Wherever possible, patient’s property must be sent home with a relative or carer. This must be recorded in the property book and would apply to both valuable and non-valuable items at all times. The relative’s name must be recorded and a date and time of the removal also inserted. Ideally the relative should confirm receipt in writing.

10. Normally, valuables should not be handed over by the Trust to third parties without the consent of the patient. However, articles of small value and clothing, from a practical point of view, should be handed to their relative or carer and a record kept. As above, names, dates, time and person’s relationship with patient should be recorded.

11. If the patient is not able to consent, or take responsibility, to property being released and the ward staff have doubts about the eligibility of the person collecting property, they must arrange for it to be stored in safekeeping until eligibility has been confirmed.

Ref: WHHT: F006

Author: Wendy Joy

Date: April 2018


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6.2 Discharge or Internal Transfers

1. The transfer of patients to other hospitals or health care organisations constitutes a discharge, within the terms of the Management of Patient’s Property Policy.

2. Patients discharged from hospital can reclaim any property held by the hospital for safekeeping, by producing their receipt, given to them at the time their valuables were handed in.

3. Where patients are transferred from ward to ward and clothing or other non-valuable property with the patient has been listed and receipted in the ward property book, the receiving ward should check the property transferred and sign the blue copy of the sending wards property book. For missing items, follow procedure in 6.7. Where valuables are already in custody in the Patient Affairs Office, the transferring ward is responsible for informing the Patient Affairs Office and the receiving ward. The property book must be updated to include where the patient is being transferred to. The receiving ward should treat the arrival as a new admission. This will help to prevent any disputes and protect staff.

4. All personal belongings should be transferred with patients. It is essential for staff to check every patient has items such as hearing aid, false teeth and glasses in their possession on transfer.

5. Where cash is involved, normally the Patient Affairs office will hold this for short term stays. For patients whose stay is on a longer basis, cash up to the value of £300 will be banked.

6. Where the patient insists on receiving cash on final discharge, Patients Affairs will arrange for the cash to be collected and taken to the ward, as near to the time of discharge as possible. The patient will be asked to produce their receipt, and counter sign the property book witnessed by a member of the ward staff.

7. Staff collecting valuables and returning them to patients must ensure that the patient signs the Ward Property Book. Staff should check the property they are receiving to ensure that it is correct before returning to the patient. Where there are large sums of cash, Patient Affairs will normally (in the interest of security), provide cheques rather than cash. Arrangements can be made with Finance to pay direct into the patient’s bank account.

8. Where it is known that a patient is due to be discharged at a weekend or a bank holiday, Patient Affairs should be contacted in advance to ensure that arrangements are made for the property to be obtained prior to the date of discharge.

6.3 Death of the Patient

1. In the event of a patients’ death, any cash and valuables previously retained by the patient, and therefore not listed in the valuables book, shall be listed and put into safe custody.

2. Any personal items, such as rings that are left on the body, must be recorded on the property book.

Ref: WHHT: F006

Author: Wendy Joy

Date: April 2018


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3. It is the responsibility of nursing staff to inform Patients Affairs Office as soon as possible of the death of a patient, for whom valuables are being held.

4. Nursing staff must not write ‘RIP’ or ‘deceased’ on property books as they may be seen by relatives. This should be left blank.

5. On occasion, the police may require access to a patients possessions. In this instance, the items should be listed in the property book, with the full name, signature and rank number of the police officer together with the reason for collection and witnessed by a member of staff.

6. Property remaining with a deceased admitted to the Mortuary is recorded into the Mortuary register.

7. When released to the Funeral Directors the Mortuary register is signed to acknowledge receipt for the property.

8. If a patient dies, having already lodged valuables with a Patients Affairs Office, this will be released to the next of kin at the time the ‘Medical Certificate of Cause of Death’ is issued. A signature is obtained from the next of kin on a receipt filed with the patient’s notes. NB this will not apply to all hospital sites where there is not a Patient Affairs Office available – please refer to local procedures.

9. In the event of relatives claiming valuables or cash of a deceased patient but refusing to meet the cost of the funeral arrangements, then no property shall be handed over until arrangements have been made to meet the cost.

6.4 Patient Property Taken into Safe Keeping

1. Valuables handed over for safekeeping must be examined, recorded in the appropriate property book and signed for by two members of staff. A signature should be obtained from the patient (where possible) to acknowledge the list of property handed over for safe custody is complete and correct. Details of any action taken must be documented in the patient’s records, (including any patient’s refusal to sign), and must be witnessed by two members of staff.

2. When recording valuables, the following details should be noted: Credit Cards the type of card e.g. visa, MasterCard, American Express, Maestro. NB: In the interest of security, the credit card number should not be recorded

3. All valuables must be placed in the ‘see through’ bag provided and closed with seals provided. Two labels are available to attach to the bag or to be enclosed with the patient’s notes. Details of contents must be recorded in the Property book. The signature of two members of staff, who have checked the contents, must then be recorded in the property book and the SPATS seal number is recorded in the property book. Where for whatever reason access is gained to the bag, a new seal and reason for the access needs to be recorded and counter signed by staff.

4. Patients must be advised that any property held with Patients Affairs, if applicable, may not be accessible at weekends, Bank Holidays or ‘out of hours’.

5. Personal property of unconscious, confused and patients with learning disabilities, who may not be able to make their own decisions, must be checked by two members of staff and handled using the transparent bag process. This sealed plastic bag

Ref: WHHT: F006

Author: Wendy Joy

Date: April 2018


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enables staff to quickly collate patient valuables on admission and deposit in the night safes.

6. When valuables and money are put into the designated transparent bag. Write the patient name, ward and hospital number on the labels provided. There are other labels available that can be either retained with the patient notes or stuck to the property book.

6.5 Transfer of Property/Valuables During/Outside of Office Hours

1. Where cash, credit cards, cheque books, jewellery etc. are involved, a member of staff from the ward/ department will take the ‘see through’ valuables bag and property book to the Patients Affairs office for custody in hours. The cashier will record the seal number in front of the member of ward staff and sign the property book to confirm receipt.

2. The receiving person will retain a copy of the form. The member of ward staff will return a signed (white) copy to the patient and keep the (yellow) copy in patient’s notes.

3. All valuables transparent bags are filed in alphabetical order and stored in the Patient Affairs safe.

4. Outside office hours and during weekends, valuables should be dealt with as below: Valuables must be entered into the Patients Property Book and signed by staff and put into the transparent valuables bag and sealed. Enter details on the white label this must be witnessed by another member of staff, signed and dated. The pink copy from the Patient Property Book must be attached to the valuables bag and the patient property transferred to the safes in A&E or AAU where it will be collected by Patient Affairs Team on the next working day.

6.6 Special Circumstances

1. Staff should ensure that patients attending theatre or outpatient procedures such as x-ray or endoscopy are not in possession of personal items, which could be removed or stored without their knowledge. They should also ensure that the patient has not left any property lying around on the ward or waiting area. In such circumstances valuables should be taken into temporary custody. Safe storage facilities must be provided for patients e.g. property bags, nurses secure office or receptacles to allow patients to carry items between changing cubicles and treatment areas.

2. Temporary custody of property and valuables should only be undertaken on wards and departments as a short-term measure, e.g. patients attending procedures or theatre, until their property and valuables can be returned to them or their relative or carer.

Ref: WHHT: F006

Author: Wendy Joy

Date: April 2018


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6.7 Missing Property/ Property Claims

1. All staff on receipt of any reported loss of valuables will instigate a thorough search of the immediate area. This will be documented in the patient’s record. In the event of the patients personal property being lost or stolen, staff must complete an incident form and advise the risk management team of the event via Datix.

2. If valuables are reported missing by a patient, the senior Sister or Nurse-in-Charge of the Unit must be informed immediately. All property books, receipts and entries must be carefully checked for details of the relevant items and if necessary, a search carried out. Security, Patient Affairs and police should be notified as soon as possible and a record kept of the Police crime number. Valuable lost property found should be documented in the patient property book and taken direct to the Patient Affairs office.

3. If a patient wishes to make a claim for lost/damaged items, they must do so as soon as possible and within 30 days of being discharged. Receipts, independent reports and proof of ownership may need to be provided. Household and other insurance policies may need to be referred to. Claims in the first instance should be directed to Patient Affairs.

6.8 Documentation/Transparent Valuable Bags

1. Each ward should have a maximum of two Property Books in use at any one time. To be treated as controlled stationery and to be properly referenced. Pages must be used sequentially. Completed Property Books are retained by the ward for two years.

2. The Patients Property Book is printed in quadruple with the distribution

of copies is as follows:

– White - Given to the patient. If the patient is not able to receive this copy it should be retained with the patient's medical records until such time as they or their relative or carer is able to receive it.

CCCooopppyyy 222 – Yellow – Filed with patient notes

CCCooopppyyy 333 – Pink - Accompanies cash and valuables and is retained by Patients Affairs.

CCCooopppyyy 444 – Blue - Retained in Property Book.

3. All spoiled copies are to be retained in the Patients’ Property Book and clearly marked ‘Cancelled’, an explanation for the cancellation written and signed by the author. Two distinct lines should be drawn from the top to the bottom of the page and the words ‘ERROR ‘be written across the page and the reason added and signed by the author.

4. The transparent Valuables bags are available in A4 size for the storage of patient valuables. These are heavy duty and clearly designated Patient Valuables and have labels for the patient’s name, number and ward on the front with the name and signature of the nurse removing the property and this person must ask someone on

Ref: WHHT: F006

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Date: April 2018


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the ward to countersign confirming that the record of contents is accurate. A second label is inside the transparent bag that can be stored with patient notes or stuck to the property page if needed.

6.9 Left Behind and Lost Property

1. All attempts will be made to reunite property with the rightful owner. However, after a period of 3 months, following discharge or death, unclaimed property will be disposed of. Care should be taken to ascertain whether articles are of value and expert advice sought where there is any doubt about the value.

2. If there are unclaimed articles of value, reasonable efforts, which should be recorded along with dates and times, should be made to trace the owner. If the trace is unsuccessful the articles should be kept for a reasonable time, normally two years before disposal, although this period of recovery may be extended.

3. Unclaimed cash and the proceeds of the sale of abandoned or unclaimed property should be credited to a holding account. When selling property if possible two valuations from reputable dealers should be sought. This will assist in showing that the Trust has been diligent in its dealing with the property. The lost property book should be updated to state what has happened to the property.

4. All clothing lost property should be retained at ward level and in the interests of hygiene, disposed of after one month.

5. All unclaimed cash which exceeds the sum of £500 after funeral costs, held on behalf of a deceased patient, must be referred to the Treasury Solicitor if the Financial Services Department have been unsuccessful in tracing any next-of-kin.

6. Where cash is held on behalf of patients, the Patient Affairs Office should make routine checks with the wards, on a monthly basis, to ensure the patient has not been discharged. It should also be the responsibility of the ward to inform the Patient Affairs Office of any change of circumstances.

7 Evaluation measures

7.1 Monitoring

All staff with responsibilities in arranging and accepting transfers must be able to record any adverse events or incidents that happen during this process using ‘Datix’ and must be reported to their Line Manager. Datix reporting will be reviewed every quarter to identify potential shortfalls in the policy/incidents relating to the management of patients property. Risks must be identified as soon as possible and action plans put in place to resolve the issue.

Issue of property books, valuables bags and property bags are controlled by Patient Affairs with all items being signed for and in the case of property books, the pink and/or green forms supplied before new books are issued. In the event of a ward misplacing the Patient Property Book this incident must be reported on Datix.

Rose Symbol Project materials can be reordered through Patient Affairs.

Patient Affairs is available to provide staff briefings and guidance on the processes for handling valuables. This includes the property book and depositing valuables in the

Ref: WHHT: F006

Author: Wendy Joy

Date: April 2018


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night safes. Briefings can be given at department team meetings or arranged on request with the Patient Services Manager.

7.2 Audit & Review

Review of the contents of this policy will take place in 3 years from date of approval. An earlier review may be needed if one or more of the following occur:

Regulatory or statutory changes or developments

Result/ effects of an incident loss, theft or fraud – trends will be captured in the analysis of incidents by the Risk Management Team

Complaints – data will capture and action plans will be devised as a result of the complaint to improve process

An audit of any aspect of the transfer process identifies areas for review and changes in practice

Audit and Root cause analysis in the management of risk of WHHT as a result of inappropriate transfers.

8 Equality Impact Assessment Statement

This policy and its impact upon equality, has been review in line with the Trust’s Equality Scheme and no detriment was identified.

9 References 1 Patient Valuables Poster

2. Patient Valuables & Property Flow Chart

Two staff members check valuables & property and complete disclaimer and or property book.

Patient advised valuables must be locked in a secure area.

All property and valuables taken into safe keeping until patient is in a position to make a decision.

Property Book

Patient hands in valuables. Place items into transparent Bag, seal and sign.

Document main items in property book noting items taken home

Ward Transfers

Patient Property book to be taken from originating area to new destination.

Property checked against original list and receiving staff signed for in Property Book. New entry made in receiving ward property book.

Transfer, Discharges and changes

Valuables

Stored in Patient Affairs / Out of hours

– Deposit Safe.

Other

Property stored in a secure area within ward or bedside

cupboard.

Transparent Bag

Valuables placed direct into Bag. Note bar code in property book.

Disclaimer

Patient retains valuables

Deceased Patients

Only Patient Affairs have authority to release a deceased patient’s valuables if deposited prior to death.

Admission

All Patients proactively asked if they have any valuables/cash in their possession.

Leaflet offered to explain options

Advise patient to return all valuables to family / relatives

Exceptions

Unconscious Patients

Confused Patients or lacking capacity

Unaccompanied Patients

Vulnerable / Safeguarding Adults

Deceased on arrival

Indemnity Form

Patient signs form Copy held with case

notes.

Changes

Patient Affairs document Pink Form.

Staff or Patient sign & collect items from Patient

Affairs.

Final Discharge

Staff or Patient sign & collect items from Patient

Affairs.

Patient Affairs will release items to staff or

patient and obtain a signature.

Ref: WHHT: F006

Author: Wendy Joy

Date: April 2018


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10 Related Policies

Security Policy

Health and Safety Policy

11 Equality Impact Assessment

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

Race NO

Ethnic origins (including gypsies and travellers)

NO

Nationality NO

Gender NO

Culture NO

Religion or belief NO

Sexual orientation including lesbian, gay and bisexual people

NO

Age NO

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

NO

Marriage & Civil partnership NO

Pregnancy & maternity NO

2. Is there any evidence that some groups are affected differently?

NO

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

N/A

4. Is the impact of the policy/guidance likely to be negative?

NO

5. If so can the impact be avoided? N/A

6. What alternatives are there to achieving the policy/guidance without the impact?

N/A

7. Can we reduce the impact by taking different action?

N/A

If you have identified a potential discriminatory impact of this procedural document, please refer it to (Insert name and position) together with any suggestions as to the action required to avoid/reduce this impact.

For advice in respect of answering the above questions, please contact (Insert name and position).

12 Policy and Procedure Sign-off Sheet

Policy Name and Number: Management of Patients’ Valuables & Property Policy, F006

Version Number and Date: September 2017 No: 3

Service Location: Patient Affairs, PMOK

All staff members must sign to confirm they have read and understood this policy.

Name Signature Name Signature

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