ACS-POL-001: Environment and accessibility for safe movement

Policy · ACS-POL-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 4.1, 4.8

At a glance

Every route a patient walks has continuous handrails, lighting and a clear floor.
Toilets have grab bars, doors that open outward or release from outside, and an accessible cubicle.
Beds, mobility equipment and call systems are safe, in working order and checked on a schedule.
The environment is surveyed each quarter, and every hazard is fixed or marked.
Stop and get help straight away if: a patient walks a route with no handrail, a toilet door that cannot be opened from outside, or a known trip hazard left unmarked.

1. Purpose

To make the facility safe to move around in for every patient, including those with mobility needs (4.1 to 4.8).

2. Scope

Applies to	Clinical and support staff in the hospital
Locations	All wards, clinics and departments of the facility
When	Whenever the activity described is carried out
Does not apply to	Activities covered by another document listed in section 15

3. Definitions

Term	Meaning
Clinical lead	The doctor or nurse in charge of the area at the time

4. Background

A cable, a box or a mat on the floor is among the commonest causes of falls in a ward. Clear routes, with any hazard that cannot be removed marked, keep patients moving safely.

5. Responsibilities

Role	Responsibility	Competence
Estates and facilities manager	Owns the environment and the survey	Management
Ward manager	Checks the ward route and equipment each shift	Senior nurse

6. Materials and equipment

Item	Requirement	Condition
Records and forms named in this document	Current version	Checked before use

7. Safety

Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.

8. Before you start

Confirm the forms and equipment named in this document are available and current.

9. Procedure

Step 1. Survey.

Survey the environment each quarter using ACS-FRM-001 and ACS-FRM-002.

Key point: The route is walked, not described.

Step 2. Fix or mark.

Fix each hazard, or mark it and manage it until it is fixed (ACS-SOP-001).

Key point: No hazard left unmarked.

Step 3. Check equipment.

Check beds and mobility equipment on the schedule in ACS-SOP-002.

Key point: Equipment is checked, not assumed.

10. Decision points

No decision points in this procedure.

11. Special situations

Situation	Action
Out of hours	Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Quarterly environment surveys completed	100%	Quarterly	Estates and facilities manager	Escalate to chief executive
Hazards fixed or marked within the set time	100%	Monthly	Estates and facilities manager	Escalate to chief executive

14. Records

Record	Kept in	Retention
Record named in this document	Patient record or the area file	the period set by the facility’s records policy years

15. Training

Staff are trained in this document at induction and refreshed each year, with a recorded competency check.

16. Related documents

ID	Title	Use
ACS-SOP-001	Environmental falls-risk survey and hazard control	Procedure
PSF-SOP-001	Falls risk assessment and prevention	Falls

17. Evidence

Reference	Note
E-009	ASF Expert Committee consensus.
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

E-learning for this document

Slip, Trip & Fall Prevention (FALL-01)
Safety & Emergency Preparedness (H-05)
Emergency Preparedness and Fire Safety (T-10)

References

Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)

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