NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST. Smoke-Free Site Policy. Documentation Control

Transcription

1 Reference HR/P&C/004 Approving Body Trust Board Date Approved 28 April 2016 Implementation Date 28 April 2016 Version 5 Summary of Changes from Previous Version NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST Smoke-Free Site Policy Documentation Control Clarifies that staff may not smoke on site or with uniform or badge showing. Inclusion of vapour cigarettes (e-cigarettes) Supersedes NUH version 2 (March 2011) Consultation Undertaken Staff Side Representatives Tobacco Control Group Policy-Sub-Group Date of Completion of Equality Impact Assessment Date of Completion of We Are Here for You Assessment Date of Environmental Impact Assessment Legal and/or Accreditation Implications Senior Management Team January 2016 January 2016 January 2016 Smoke-free legislation 2006 Public Health England 2015 Health and Safety at work

2 NICE PH48 Target Audience All staff, patients, visitors, students, contractors and other persons visiting the campuses of the Trust. Review Date January 2019 Lead Executive Author/Lead Manager Further Guidance/Information Medical Director Stephanie Beasley-Thompson Human Resources CONTENTS Paragraph Title Page 1. Introduction 4 2. Executive Summary 4 3. Policy Statement and Scope 5 (including e-cigarettes) 4. Roles and Responsibilities All employees End-of-life Managers Employees working off-site Residents on site Leased Buildings on site Policy Definitions 8 6. Training and Implementation 9 7. Impact Assessments 10

3 8. Monitoring Matrix Relevant Legislation, National Guidance 12 and Associated NUH Documents Appendix 1 Resources 12 Appendix 2 Equality Impact Assessment 13 Appendix 3 Environmental Impact Assessment 16 Appendix 4 Here For You Assessment 18 Appendix 5 Certification Of Employee Awareness 20

4 1 Introduction NUH has a duty to protect the health of people who use or visit our services, and our employees. This duty includes providing them with effective support to stop smoking. It is against the law to smoke in our premises. The National Institute for Health and Care Excellence (NICE) published guidance (2013) to support smoking cessation, temporary abstinence, and smoke-free policies. NICE recommends that all secondary healthcare premises (including grounds and vehicles) remain free of tobacco smoke. This Policy commits the Trust to enforcing the requirements of smoke-free legislation (2006), and to adopting the recommendations described by National Institute for Health Care Excellence (2013). Electronic cigarettes ( vaping ) E-cigarettes do not contain tobacco and are therefore not covered by smoke-free legislation. A recent Public Health England Evidence Review concluded that e-cigarettes were 95% safer than "traditional" cigarettes, and recent studies have demonstrated that e-cigarettes can help people to stop smoking or reduce cigarette consumption. E-cigarettes should be considered a potential nicotine replacement therapy. This Policy prohibits their use in our

5 premises, but permits their use in our grounds. 2 Executive Summary This Policy describes the prohibition of cigarette smoking in the Trust s premises and grounds, and in vehicles used for Trust business. It describes that the Trust will support patients and staff to abstain from cigarette smoking. 3 Policy Statement and Scope The aim of this Policy is to: Improve the health of patients, visitors (including contractors) and employees Protect patients, visitors and staff from exposure to secondhand smoke Set an example to other employers This Policy applies to all staff, patients, visitors, students, contractors and other persons visiting, working or living on the sites of Nottingham University Hospitals NHS Trust. The Trust acknowledges that cigarette smoking is addictive and that staff smokers may experience symptoms at work if they do not have access to cigarettes or Nicotine Replacement Therapy (NRT), particularly if they are working a long shift. It is important that staff in this category are encouraged (and given appropriate time to

6 attend Occupational Health or an alternative source of NRT and/ or cessation advice. There is no contractual right to a break for the purposes of cigarette smoking, and smokers are not entitled to longer breaks than non-smoking colleagues All those covered by this Policy who wish to stop smoking will be helped to access individual or group support and nicotine replacement therapies as appropriate. Appendix 1 contains details of local and national stop-smoking support resources. Occupational Health is a further source of support for employees who wish to stop smoking. The Trust considers e-cigarettes a ppotential nicotine replacement therapy. For this reason this Policy permits their use in Trust grounds (but prohibits their use in Trust buildings).

7 4 Roles and Responsibilities All employees All NUH employees; permanent, temporary (bank, agency or locum), will promote a smoke-free environment. Employees must not smoke tobacco on the Trust s sites. Employees must not smoke tobacco when identifiable as an NUH employee (in visible uniform or wearing an NUH badge). Employees must not smell of tobacco smoke when on Trust business. Employees must not smoke tobacco in their personal vehicle if travelling on Trust business or on a Trust site. Employees should not accompany patients who wish to go outside its premises to smoke tobacco. All patients should be offered advice and support re smoking cessation. Exceptionally, in the last few days of life, it may be considered by the ward manager (or deputy) appropriate to permit a patient who does not wish to give up cigarettes to smoke Whenever practicable this should be off-site. In very exceptional circumstances it may be on-site (in Trust grounds, not premises), but it must be done discretely, must not expose others to cigarette smoke, and must not require an employee to accompany the

8 patient Employees who find compliance with the Policy difficult (by reason of their addiction) should speak to their line manager who will signpost them to appropriate support. Should an employee infringe this Policy they will be dealt with under the Disciplinary Policy: a breach of this Policy may be deemed gross misconduct, and may result in termination of contract. Employees should support this Policy by asking anyone they know to be smoking on Trust premises or grounds to stop smoking or to leave the premises (or grounds) immediately. The Trust recognises there will be occasions where an employee does not feel confident to challenge a smoker. If a smoker does not respond to a polite request the employee should contact Security immediately. All employees should ensure that their patient(s) are aware of the Trust s Smoke-free Policy and sources of support (including NRT) Managers Managers must stipulate adherence to this Policy as a contractual condition in all tenders and contracts with the Trust. Managers must include reference to this Policy in all steps of recruitment (job advertisements and job descriptions and interview) and state that adherence is a contractual duty.

9 Managers must ensure that all NUH Employment Contracts state the following: Nottingham University Hospitals NHS Trust operates a no smoking Policy. Employees are not permitted to smoke anywhere on Trust premises or grounds, or when readily identifiable as a Trust employee. Managers must ensure that there is reference to this Policy of no smoking in the Trust or in the presence of Trust employees, and that cessation support is available, in all notifications to patients of appointments or admissions. Employees working off site The prohibition on smoking cigarettes applies to staff on Trust business off the Trust s sites. Employees have a right not to be exposed to cigarette smoke while on Trust business visiting patients in their own homes. If exposed to second-hand smoke in a patient s home, staff should advise them of NUH s Smoke-free Policy, and ask that they (or others) do not smoke in their presence. If smoking continues in the employee s presence, the employee should leave the environment, provided this does not compromise patient safety. In such circumstances the employee of staff should inform their line manager and the patient s Consultant/GP (where appropriate). Residents on site

10 Residents of buildings on site (as defined above) are expected to comply with this Policy as it applies to the Trust s premises and grounds, and with their contractual lease arrangements. Leased Buildings on Site Organisations that lease space from the Trust are expected to enforce this Policy. Adherence to the Policy shall be a condition of any lease. This includes the staff social club at City Hospital. 5 Policy Definitions Nottingham University Hospitals NHS Trust is a Smoke-Free Site. The Smoke-Free Site covers the whole of QMC, City Hospital and Ropewalk House. The boundaries of each site are the public highways/pavements that form their perimeter. All internal grounds, roads and pavements are on-site. At QMC the perimeter public highways/pavements are Derby Road, Store Road and Clifton Boulevard. At City Hospital the perimeter public highways/pavements are Hucknall Road and Edwards Lane. At Ropewalk House the perimeter public highways/pavements are The Ropewalk and Park Row. The site-wide smoke-free restriction does not include e-cigarettes (also known as vapour cigarettes). However e-cigarettes must not be used inside Trust buildings.

11 6 Training and Implementation 6.1 Staff require training around making patients aware of the Policy, signposting patients to appropriate support ( brief intervention ), and challenging patients visitors and colleagues who are smoking in the Trust. The Trust will make such training available to those staff identified in a TNA, and monitor its uptake Implementation Overall responsibility for implementing this Policy rests with the Director of Workforce. Day-to-day responsibility for implementation lies with all managers and staff. The effectiveness of this policy will be measured by evaluating the number of complaints / comments received by PALS regarding smoking on site on a quarterly basis, by reports by staff of smoking on our premises and grounds, and by the outcomes of PLACE and other inspections of our premises.

12 7 Impact Assessments 7.1 Equality Impact Assessment An equality impact assessment has been undertaken on this Policy and has not indicated that any additional considerations are necessary. 7.2 Environmental Impact Assessment An environmental impact assessment has been undertaken on this Policy and has not indicated that any additional considerations are necessary. 7.3 Here For You Assessment A Here For You assessment has been undertake on this Policy and has not indicated the need for any additional considerations.

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14 8.0 Policy / Procedure Monitoring Matrix Responsible individual/ group/ committee Process for monitoring e.g. audit Frequency of monitoring Responsible individual/ group/ committee for review of results Responsible individual/ group/ committee for development of action plan Responsible individual/ group/ committee for monitoring of action plan Number of complaints linked to smoking PPISG PPISG Quarterly PPISG PPISG PPISG 9 Relevant Legislation, National Guidance and Associated NUH Documents 9.1 Smoke-free legislation 2006, APPENDIX 1

15 RESOURCES NUH Occupational Health Department X NUH Pharmacy NHS New Leaf Stop Smoking Service Nottingham City Telephone: Smokefree National Helpline on City stop smoking County stop smoking

16 Insert templates of relevant impact assessments (page break after each) APPENDIX 2 Equality Impact Assessment (EQIA) Form (Please complete all sections) Q1. Date of Assessment: Q2. For the policy and its implementation answer the questions a c below against each characteristic (if relevant consider breaking the policy or implementation down into areas) Protected Characteristic a) Using data and supporting information, what issues, needs or barriers could the protected characteristic group s experience? i.e. are there any known health inequality or access issues to consider? The area of policy or its implementation being assessed: b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality Race and Ethnicity Gender Age Religion Disability No Impact No Impact No Impact No Impact No Impact

17 Sexuality No Impact Pregnancy and No Impact Maternity Gender No Impact Reassignment Marriage and No Impact Civil Partnership Socio-Economic No Impact Factors (i.e. living in a poorer neighbour hood / social deprivation) Area of service/strategy/function Q3. What consultation with protected characteristic groups inc. patient groups have you carried out? Consultation with Staff Side was implemented. Patient Representatives were also consulted. No changes were made as it was not felt that the policy discriminated in any way. Q4. What data or information did you use in support of this EQIA? As this was a re-draft of a Policy, the original Policy was used as a starting point for the research stage. Policies from other NHS Trusts were reviewed to share best practice. A meeting was also held with key stakeholders (including staff side, patient representatives, Communications, Estates and Facilities, Occupational Health) to brainstorm ideas for inclusion in the re-drafted Policy Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? n/a Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups

18 identified or to create confidence that the policy and its implementation is not discriminating against any groups What By Whom By When Resources required Q7. Review date January 2017

19 APPENDIX 3 Environmental Impact Assessment The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b) implement mitigating actions. Area of impact Environmental Risk/Impacts to consider Action Taken (where necessary) Waste and Is the policy encouraging using more materials/supplies? materials Is the policy likely to increase the waste produced? Does the policy fail to utilise opportunities for introduction/replacement of materials that can be recycled? Soil/Land Is the policy likely to promote the use of substances dangerous to the land if released (e.g. lubricants, liquid chemicals) Does the policy fail to consider the need to provide adequate containment for these substances? (e.g. bunded containers, etc.) Water Is the policy likely to result in an increase of water usage? (estimate quantities) Is the policy likely to result in water being polluted? (e.g. dangerous chemicals being introduced in the water) Does the policy fail to include a mitigating procedure? (e.g. modify procedure to prevent water from being polluted; polluted water containment for adequate disposal) Air Is the policy likely to result in the introduction of procedures and equipment with resulting emissions to air? (e.g. use of a Bins will be provided at all entrances to Trust Grounds Not Applicable Not Applicable

20 furnaces; combustion of fuels, emission or particles to the atmosphere, etc.) Does the policy fail to include a procedure to mitigate the effects? Does the policy fail to require compliance with the limits of emission imposed by the relevant regulations? Energy Does the policy result in an increase in energy consumption levels in the Trust? (estimate quantities) Nuisances Would the policy result in the creation of nuisances such as noise or odour (for staff, patients, visitors, neighbours and other relevant stakeholders)? Not Applicable All staff are expected to act in line with the Trusts Values and Behaviours when leaving the site to smoke

21 APPENDIX 4 We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit The We Are Here For You service standards have been developed together with more than 1,000 staff and patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe and confident in their treatment. The standards apply to how we behave not only with patients and visitors, but with all of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their inclusion in Policies and Trust-wide Procedures is essential to embed them in our organization. Please rate each value from 1 3 (1 being not at all, 2 being affected and 3 being very affected) Value Score (1-3) 1. Polite and Respectful 2 Whatever our role we are polite, welcoming and positive in the face of adversity, and are always respectful of people s individuality, privacy and dignity. 2. Communicate and Listen 1 We take the time to listen, asking open questions, to hear what people say; and keep people informed of what s happening; providing smooth handovers. 3. Helpful and Kind 1 All of us keep our eyes open for (and don t avoid ) people who need help; we take ownership of delivering the help and can be relied on. 4. Vigilant (patients are safe) 2 Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates attention to detail for a clean and tidy environment everywhere. 5. On Stage (patients feel safe) 2

22 We imagine anywhere that patients could see or hear us as a stage. Whenever we are on stage we look and behave professionally, acting as an ambassador for the Trust, so patients, families and carers feel safe, and are never unduly worried. 6. Speak Up (patients stay safe) 1 We are confident to speak up if colleagues don t meet these standards, we are appreciative when they do, and are open to positive challenge by colleagues 7. Informative 1 We involve people as partners in their own care, helping them to be clear about their condition, choices, care plan and how they might feel. We answer their questions without jargon. We do the same when delivering services to colleagues. 8. Timely 1 We appreciate that other people s time is valuable, and offer a responsive service, to keep waiting to a minimum, with convenient appointments, helping patients get better quicker and spend only appropriate time in hospital. 9. Compassionate 1 We understand the important role that patients and family s feelings play in helping them feel better. We are considerate of patients pain, and compassionate, gentle and reassuring with patients and colleagues. 10. Accountable 1 Take responsibility for our own actions and results 11. Best Use of Time and Resources 1 Simplify processes and eliminate waste, while improving quality 12. Improve 1 Our best gets better. Working in teams to innovate and to solve patient frustrations TOTAL 15

23 CERTIFICATION OF EMPLOYEE AWARENESS APPENDIX 5 Document Title Smoke Free Site Policy Version (number) 4 Version (date) 28 April 2016 I hereby certify that I have: Identified (by reference to the document control sheet of the above policy/ procedure) the staff groups within my area of responsibility to whom this policy / procedure applies. Made arrangements to ensure that such members of staff have the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Signature Print name Date Directorate/ Department The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). The suggested level of certification is; Clinical directorates - general manager Non clinical directorates - deputy director or equivalent. The manager may, at their discretion, also require that subordinate levels of their directorate / department utilize this form in a similar way, but this would always be an additional (not replacement) action.