Stay informed with the latest updates on coronavirus (COVID-19). Find out more >>

Policies and Procedures


  • 1. Purpose of Security Card Access and Identification at RCH

    Security at the Royal Children's Hospital (RCH) is managed in a Public Private Partnership with Spotless Security Services (email ) and The Royal Children's Hospital Facilities Management.

    The key purpose of the security function at RCH is to:

    • Ensure safety for our patients, families and staff.
    • Facilitate thorough credentialing of all staff.
    • Provide clear record of identity, employing body and professional status.
    • Limit private, sensitive and high risk areas to appropriately qualified staff. 

    In line with the above, ALL staff members and visitors requiring security access to restricted areas of the hospital MUST fulfil the Credentialing process outlined in 2.0 below. The credentialing process is managed by hosting departments of the hospital as follows:

    • All paid RCH Staff Members and practising Honorary Doctors will have their credentials managed centrally by Human Resources and Medical Workforce Unit (MWU)
    • All Visitors (non-paid staff including external partnerships, volunteers, students, observers, medical appointments, non-clinical honoraries, specialist groups and contractors) have their credentials managed by the Head of Department, or delegated RCH contact.

    2. Credentialing

    Security access should not be granted without completion of the RCH credentialing process.

    Credentialing a staff member/visitor involves the following:

    2.1 Executive approval of both purpose and objectives resulting from visit to RCH.

    2.2 Working with Children Check (receipt of application will be accepted in the first week).

    2.3 Fit 2 Work Police Check (A Statutory Declaration stating 'no prior convictions' is acceptable, where Fit 2 Work checks are delayed or recently acquired).

    2.4 Qualifications against defined scope of practice - for all clinical staff.

    2.5 The RCH Visitor Policy Currently States that:

    • Students only require WWC and Fit2Work if they are to be engaged with RCH for a period greater than two weeks. It is understood that non-credentialed students will be supervised at ALL times and therefore should not require special Security access, or RCH ID. Students undertaking studies for a period greater than two weeks must to be credentialed by the tertiary institution to which they belong. If they require IT log-in, then they will be required to produce their own WWC and Fit2Work to the RCH delegate.
    • All Honorary Doctors ( practicing) and Locums are to be managed by the MWU, including their WWC and Fit2Work. 
    • Medical Observers must supply their own WWC and Fit2Work prior to being accepted to RCH. If they are overseas Observers, they must supply a Police Check from their country of origin in English, or provide a certified transcript. They should arrange this and email the documentation to the hosting department prior to their arrival.
    • RCH Payment for Fit2Work is for paid RCH staff only .  All new staff must supply their own WWC receipts prior to their commencement. The process states that Statutory Declarations can be accepted in the event that a staff member needs to commence employment with RCH prior to receipt of their Fit2Work approval. 
    • University of Melbourne  and MCRI (Murdoch Childrens Research Institute) Visitors will be managed by each of the relative parties and they will send through their Visitor Spreadsheets to Spotless via email.

    3. Access Levels in RCH

    The Royal Children's Hospital has adopted an open door policy with regard to general access areas across the hospital for all staff.

    General access includes all areas deemed 'safe' or 'low risk', such as lift wells, HELP precinct, and free amenities, such as the Meerkats enclosure and food and beverage retailers.

    It is also important to note that wards are open to the public during business hours (7am to 7pm). Therefore, the majority of visitors to the hospital, including the general public, do not require security access.

    3.1 General Access

    The majority of staff engaged at the Royal Children's Hospital have a 'general level access' security profile which provides access to amenities such as the bike shed and shower facilities; Corporate Offices; HELP precinct (security swipe rooms included); Education Resource Centre; Library, Medical Workforce Unit; and lift wells after hours. 

    3.2 Additions to General Access Levels

    As there are a number of high risk areas within the hospital including medicine supplies; radiation; toxic chemical storage; high voltage electrical areas; and infection control, the appropriate access rights to these areas will only be assigned to staff who have been formally credentialed by the RCH to work in the specified risk area. The list of staff roles with specific security access rights is managed by the Facilities Manager in the Finance & Corporate Department.

    4. Types of Security Access Cards

    There are several types of security access cards available at The Royal Children's Hospital, and allocation of these is dependent on the type of engagement.

    4.1 RCH Staff Security Photo ID (Issued by Spotless)

    Staff members employed and paid by the Royal Children's Hospital are required to obtain a security photo ID from Spotless Security. Paid staff and their conditions of engagement are managed via the Payroll system (Chris21) centrally in Human Resources. This includes staff on-boarding, credentialing, variation to employment and termination of security access. Some ongoing contracted staff will fall under this process also.  

    Managers must allow 3-4 weeks from the date of staff selection to their commencement date, otherwise access and systems may not be available to staff on their first day. New Starters are advised in their RCH New Starter pack disseminated via email that they MUST return all their paperwork prior to their commencement date. HR will need 3 business days to update new starter details in the Payroll system, which will then provide access to a security pass and IT log-ins

    Staff will be required to present Photo ID in order to obtain their security pass.

    4.2 Non-Paid Visitors to RCH

    Visitors conditions of engagement will be managed by the Hosting Department or RCH approved Management Group (e.g Volunteers, Starlight, Auxiliaries). Visitor conditions of engagement will be managed by the Hosting Department or Management Group (e.g. Volunteers, Starlight, Auxiliaries).

    4.2.1 Visitor Security Photo ID (Issued by Spotless)

    Full Security Photo ID, issued by Spotless, can be obtained by completing the " Security Photo ID " form available at the Spotless Security desk, located next to the Emergency Department on the Lower Ground Floor. Security Photo ID is required if any of the statements below apply to the Visitor engagement at RCH:

    • The Visitor requires regular access to the hospital over a sustained period of time (i.e. more than once a week, and over a period of at least six months).
    • The Visitor will have access to patients and families on a professional basis without RCH supervision.  
    • The Visitor requires special access to medicine supplies, or areas deemed high risk such as Medical Imaging. 
    • The Visitor requires IT log-ins in line with RCH Privacy.

    Again, if security access is required, then the Visitor MUST obtain a Working with Children Check (WWC) and Fit to Work Police Check before they will be granted access.

    4.2.2 Temporary Visitor Cards (Issued by Spotless) - [click here to download copy of Application Form]

    Any Visitors who fall outside the above 4.2.1 list of RCH engagement conditions can be issued with a temporary, non-photo access pass by Spotless. Temporary Security General Access Day Passes can only be obtained by the following process:

    • Prior notification in writing of the person's full name, date of visit and Department they will be attending
    • The Visitor must present a formal letter from RCH as proof of reason to visit the hospital
    • The Visitor must also show photo identification to obtain the pass 
    • The pass must be returned at the end of the visit and signed out 

    4.3 Patient and Family Access Cards (Issued by the Wards) 

    Inpatients and their family members are provided with Visitor cards for after-hours visits, as the wards lock down from 7pm to 7am to improve safety.  These are returned to the ward each morning.   

    5. Title Allocation on Staff Security Photo ID Access Cards

    The Executive approved a number of generic titles to be assigned to staff security ID cards (See Appendix B for full list). Therefore, the titles which appear on security access cards have no bearing on actual assigned titles (e.g. in the payroll system, or on business cards). There were a number of reasons it was decided to assign largely generic titles to the cards:

    1. Provide an easy way for parents and patients to differentiate between clinical and non-clinical staff at RCH
    2. Limit the number of titles used to ease recognition and administration by Security staff
    3. Ensure most titles fit on the small space available on cards

    The following guiding principles apply in the application of generic titles to cards:

    • Any non-clinical staff member with a role in a clinical area (e.g. hospital wards) will have the title 'Administration', even if they are a manager. This is to delineate clearly 'clinical' from 'non-clinical' staff members to the public who access those areas.
    • As the general public does not access the corporate offices, the title of 'Manager' may be used in these areas on the ID cards. However, they should report to a Director.
    • The term ' Director' must only be used in cases where the staff member holds a Director position, and reports to an Executive Director.
    • The terms ' Professor' and 'Associate Professor' may be used.
    • The term ' Doctor' is only to be used for a practicing, clinical doctor. It cannot be used for non-practitioners who simply hold a PhD, or are not up-to-date with their credentialing and registration.

    It should be noted that titles of staff who work in high risk areas in the hospital (i.e. have additional security access rights to the general access) are linked to the security profiles associated with them. This is managed by the RCH Facilities Manager in the Finance and Corporate Division.

    Spotless do not have the authority to amend titles or access profiles.

    6. Changes to Security Access Profile  

    Security profiles are attached to positions in RCH. Therefore, all requests for changes to Security Access profiles must go through via an email to the Facilities Department

    7. Staff Terminations

    Paid Staff terminations and subsequent de-activation of cards and access will be facilitated by the Chris21 Payroll System and the Active Directory. Managers should collect cards of terminated employees and send them to the Human Resources Department via internal mail.

    All Visitors should hand in their cards to Spotless Security upon the termination of their engagement with the Royal Children's Hospital.