Document Control Report

Smoke Free Policy Northern Devon Healthcare NHS Trust Incorporating Community Services in Exeter, East and Mid Devon

Correct on the day of printing. Please check on the Trust’s internet site for the most up to date version

Document Control Report

Title Smoke Free Policy

Author Alison Diamond

Author’s job title Medical Director

Directorate Medical

Sub-directorate

Department

Team / Specialty

Version Date

Issued Status Comment / Changes / Approval

0.1 Oct 2006

Draft Presented to Staff Side for comment -16.10.06

0.2 Nov 2006

Draft Presented toTrust Board for comment - 22.11.06

1.0 Feb 2007

Final Approved by Trust Board.

1.1 Jan 2008

Revision Public Health Strategy Group – reviewed 31.01.08

1.2 Feb 2008

Revision Minor amendments following Executive Team meeting – 27.02.08

1.3 Aug 2008

Revision To clarify policy and separate out procedures in order to ensure compliance.

1.4 Sep 2008

Revision Final amends to ensure corporate identity.

1.5 Oct 2008

Revision Further corporate amends following receipt of amended version from the Director of Development which included clarification on uniform amend and additional clause to support health promotion role of NHS staff.

1.6 Dec 2008

Revision Further re-draft re-amended into corporate template in accordance with the Policy on Policies.

2.0 Feb 2009

Final Amends to incorporate clarity on some areas Ratified at Trust Board 7 April 2009.

2.1 May 2009

Revision Corporate Affairs amendments to Document Control Report and dates to match ratification by Board. Correction in Section 5 to reference section 13.

2.2 Oct 2009

Revision Author and contact details updated, following departure from the Trust of the previous author / main contact.

2.3 Feb 2011

Revision Minor amendments by Corporate Affairs to format text for document map navigation and update the document control report. Contents page numbering corrected.

2.4 Dec 2011

Revision Harmonised policy as a result of the merging of Northern Devon Healthcare NHS Trust and NHS Devon community services. A summary of key issues and differences is on page 3. Approved by xxxx on xxxx following consultation.

2.5 Feb 2012

Revision Minor amendments by Corporate Governance to update the document control report. Contents page numbering corrected. Presented to Trust Board on 28.02.12 for approval.

Medical Director Page 1 of 22 Annex 4.2 Board 28.02.12 - Smoke Free Policy v3[1] Part 2


Main Contact Alison Diamond, Associate Medical Director North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB

Tel: Direct Dial - 01271 322792 Tel: Internal – 2792 Email: [email protected]

Lead Director Medical Director Document Class Policy

Target Audience All staff, patients, contractors, visitors and other persons who enter Northern Devon Healthcare Trust owned, rented or leased buildings, enclosed areas or grounds for any purpose whatsoever.

Distribution List Senior Management Compliance Manager

Distribution Method Trusts intranet site

Superseded Documents NDHT Smoke free policy (v2.3 2011) NHS Devon / Devon Provider Services Smoke free policy HR03 (v2 2011) Issue Date February 2012

Review Date TBC

Review Cycle Three years

Contact responsible for implementation and monitoring compliance: Medical Director

Consulted with the following stakeholders: (list all) Public Health Team

Occupational Health

Facilities Department

Communications

Corporate Governance

Human Resources

Learning and Development

Staffside policy group

Health & Safety Committee

Trust Board

Education/ training will be provided by:

Approval and Review Process Trust Board

Ratified by Trust Board? Yes

Archive Reference G:\ Associate Medical Director Path \Public Health\Smoke-free Policy Filename Annex 4.2 Board 28.02.12 - Smoke Free Policy v2.5 22Feb12 Part 2.doc Categories for Tarkanet All staff, Harmonised

Tags for Tarkanet Smoking, cigarettes

Any revision to an NHSLA policy requires the agreement of the Compliance Manager




Summary of key differences and main changes in this harmonised policy

compared to the Northern and Eastern policies Staff are expected to review the complete policy’s contents.

Section

Ref. Key Differences / Changes

2 Extension of the Trust smoke free environment from all of its buildings and enclosed areas, to its land and grounds.

5.1 Promotion of Nicotine Replacement Therapy.

5 On admission, all patients will have their smoking status recorded using the admission procedures and be referred to the cessation service where appropriate.


Contents

1 ………………………….. .............................................................................. 6 Introduction

2 ………………………………............................................................................... 6 Purpose

3 ……………………………………… ................................................................ 8 Definitions

3.1 .............................................................................................................. 8 Premises

3.2 8 Associated Premises............................................................................................

4 10 Roles and Responsibilities ............................................................................................

4.1 ................................................................................ 11 Role of the Chief Executive

4.2 ......................................................................... 11 Role of Directors and Managers

4.3 ................................................................................................... 11 Role of All Staff

4.4 .............. 11 Role of the Facilities Department, including Tenders and Contractors

4.5 ................................................................................. 12 Role of Human Resources

4.6 ............................................................................... 12 Role of Occupational Health

4.8 .................................................................................... 12 Role of Communications

4.9 .................................................................. 12 Role of Patients, Public and Visitors

5 ..................................................................... 13 Implementation of this smoke free policy

5.1 ............................................................ 14 Nicotine Replacement Therapy Support

6 14 Breaches of the Policy………………….. .......................................................................

6.1 ..................................................................... 14 Surveillance of the Front Entrance

6.2 ....................................................... 15 Surveillance of the Maternity Unit Entrance

7 .................................................................................... 15 The Development of the Policy

7.1 .......................................................................................... 15 Prioritisation of Work

7.2 ....................................................................... 15 Document Development Process

7.3 .............................................................................. 15 Equality Impact Assessment

8 ......................................................... 15 Consultation, Approval and Ratification Process

8.1 ......................................................................................... 15 Consultation Process

8.2 ..................................................................................... 16 Policy Approval Process

8.3 ............................................................................................ 16 Ratification Process

9 ............................... 16 Review and Revision Arrangements including Document Control

9.1 ....................................................................... 16 Process for Reviewing the Policy

9.2 .......................................................................... 16 Process for Revising the Policy

9.3 .............................................................................................. 16 Document Control

10 .............................................................................. 16 Dissemination and Implementation



10.1 ................................................................................ 16 Dissemination of the Policy

10.2 .............................................................................. 17 Implementation of the Policy

11 .................................................. 17 Document Control including Archiving Arrangements

11.1 ....................................................................... 17 Library of Procedural Documents

11.2 ..................................................................................... 17 Archiving Arrangements

11.3 .............................................................. 17 Process for Retrieving Archived Policy

12 ........... 17 Monitoring Compliance With and the Effectiveness of Procedural Documents

12.2 ............................................................. 17 Standards/ Key Performance Indicators

12.3 ...................................... 17 Process for Monitoring Compliance and Effectiveness

13 ................................................................................................................... 18 References

14 .......................................................................................... 18 Associated Documentation

Appendix A: Smoking Admission Protocol ........................................................................... 19

Appendix B: Equality Impact Assessment Screening Form ................................................. 20



1 Introduction

This policy is fundamental to the Trust’s desire to play an exemplary health promotion role as a health care organisation supporting a smoke free environment, for the benefit of all patients, staff and visitors. This document sets out the agreed hospital protocols for inpatients, outpatients, visitors and staff who smoke. It also sets out the specialist smoking cessation support available to patients and staff and promotes the use of Nicotine Replacement Therapy.

The aim of this policy is to achieve a tobacco-free environment, for the benefit of all patients, staff and visitors. This Trust recognises that second hand smoke adversely affects the health of all persons and is not concerned with whether anyone smokes, but with where they smoke and the effect this has on patients, visitors, staff and other members of the wider health community.

This policy should be read in conjunction with the Northern Devon Healthcare NHS Trust’s Health and Safety policy and policy statement.

The Public Health White Paper, Choosing Health, made a clear commitment to a smoke free NHS by the end of 2006.

Several EU directives relating to health and safety in the workplace have come into force since 1st January 1993. These include the Management of Health and Safety at Work Regulations 1999 which, under General Principles of Prevention, include:

Avoiding risks.

Combating risks at source.

Replacing the dangerous by the non-dangerous or the less dangerous.

Giving collective protective measures priority over individual protective measures.

Second-hand smoke – breathing other people’s tobacco smoke – has now been shown to cause lung cancer and heart disease in non-smokers, as well as many other illnesses and minor conditions.

2 Purpose

On 1 July 2007, England introduced a new law to make virtually all enclosed public places and workplaces in England smoke free. The purpose of this was to protect employees and the public from the harmful effects of second hand smoke. Consequently, it is now illegal for people to smoke in Northern Devon Healthcare NHS Trust owned buildings or in any associated enclosed areas.

The Northern Devon Healthcare NHS Trust as an employer has a duty to reduce risk in the workplace and look after the welfare of its staff and, as a provider of health care services, the Trust has a core responsibility to improve people’s health and opportunity to promote good public health. Smoking is the biggest single cause of ill health and premature death in the UK and second hand smoke – breathing other people’s smoke – has now been shown to cause lung cancer and heart disease in non smokers, as well as many other illnesses and minor conditions. Some key facts include:


http://ndht.ndevon.swest.nhs.uk/policies/?p=5203


Passive smoke contains over 50 known carcinogens. The increased risks for adults who live with smokers are: lung cancer 20-30%; heart disease 25%. For children they are: sudden infant death syndrome 50%; lower respiratory tract illness 50%; asthma 50%; middle ear disease 40% (CMO Annual Report 2002).

Smoking outside entrances (and in other public places) presents a poor image. People smoking at the entrance to NHS buildings give a very poor impression of the health organisation and this also means that those entering and leaving the buildings have to pass through tobacco smoke.

Smoking can present a fire safety hazard. Section 2(2)(e) of the Health and Safety at Work Act 1974 places a duty on employers to “… provide and maintain a safe working environment which is, so far as is reasonably practical, safe, without risks to health, and adequate as regards facilities and arrangements for their welfare at work.”

The employer acknowledges that breathing other people’s smoke is both a public health hazard and a welfare issue. Therefore, the following policy has been adopted concerning smoking at all Trust premises, buildings and grounds.

For these reasons the Trust is extending the smoke free environment covered within the legislation to cover, not only all of its buildings and enclosed areas, but also its land and grounds.

This policy applies to all staff, patients, contractors, visitors and other persons who enter the Northern Devon Healthcare NHS Trust owned, rented or leased buildings, enclosed areas or grounds for any purpose whatsoever and includes vehicles used for Trust business and/or staff-owned vehicles when on Trust grounds (see Section 3.1 Premises). The policy is also effective for all employees whilst working at the Trust’s associated sites. Staff working at premises not owned, rented or leased by the Trust will be expected to adhere to these sites Smoking Policies.

Implementation of this policy will:

Protect and improve the health of staff.

Protect and improve the health of patients, visitors and contractors.

Motivate and support smokers who wish to quit by providing smoking cessation advice with minimum costs to the individual.

Protect both smokers and non-smokers from the danger to their health of exposure to second hand smoke.

Set an example to other employers and workforces, particularly in health related locations.

Demonstrate the Trust’s leadership role in public health and health provision by arranging for Trust buildings, properties and vehicles to be ‘smoke-free’ and by requiring staff not to smoke while in paid working time or in an identifiable NHS or Northern Devon Healthcare NHS Trust uniform.

Comply with Department of Health legislation and guidance.



3 Definitions

3.1 Premises

For the purposes of this policy, Trust premises include any and all Trust owned or rented buildings and any and all Trust owned or rented grounds. These are as follows:

Primary Sites

North Devon District Hospital

Raleigh Park, Barnstaple, Devon, EX31 4JB

Moretonhampstead Hospital

Forde Street, Moretonhampstead, TQ13 8LY

Axminster Community Hospital

Chard Street, Axminster, EX13 5AQ

Okehampton Hospital

Cavell Way, Okehampton, EX20 1PN

Barnstaple Health Centre

Vicarage St, Barnstaple, EX32 7BH

Ottery St Mary Community Hospital

Keegan Close, Ottery St Mary, EX11 1DN

Bideford Hospital

Abbotsham Road, Bideford, Devon EX39 3AG

Seaton Community Hospital

Valley View, Seaton, EX12 2UU

Budleigh Salterton Community Hospital

East Budleigh Road, Budleigh Salterton, EX9 6LS

Sidmouth Hospital

All Saints Road, Sidmouth, EX10 8EW

Crediton Hospital

Western Road, Crediton, EX17 3NH

South Molton Hospital

Widgery Drive, South Molton, Devon, EX36 4DP

Exmouth Community Hospital

Claremont Grove, Exmouth, EX8 2JN

Tiverton Hospital PFI

Kennedy Way, Tiverton, EX16 6RS

Holsworthy Hospital

Dobles Lane, Holsworthy, Devon EX22 6JQ

Torrington Hospital

Calf Street, Torrington, Devon, EX38 7BJ

Honiton Hospital

Marlpitts Lane, Honiton, EX14 2DE

Whipton Hospital

Hospital Lane, Whipton, Exeter, EX1 3RB

Ilfracombe Tyrrell Hospital

St Brannocks Park Road, Ilfracombe, Devon, EX34 8JF

3.2 Associated Premises

Associated premises are those locations where employees Northern Devon Healthcare NHS Trust Incorporating Community Services in Exeter, East and Mid Devon may also work. Staff within these premises will be expected to comply with the Smoke Free Policy of these NHS premises.

Associated Sites – where Trust Employees have designated workspace

Other NHS & DCC premises

Country Hall - Topsham Road, Exeter, EX2 4QD

Crown Yealm House, Pathfields Industrial Estate, South Molton, EX36

RD&E Heavitree - Community Chiropody & Dental Services, Wonford

St Edmunds Court, 16 Okehampton St, Exeter, EX4 1DU



3LH Hospital, Barrack Road, Exeter, EX2 5DW

Alphin Residential House, Mill Lane, Exeter EX2 8SG

Exeter Airport, Exeter, EX5 2BD

Newcourt House, Old Rydon Lane, Exeter, EX2 7JU

Sycamores Resource Centre, Mount Pleasant Road, Exeter, EX4 7AE

Bodley Community Care Centre, Wayside Cr, Exeter EX1 3LF

Franklin House, Franklyn Drive, Exeter, EX2 9HS

North Devon Hospice, Deer Park, Newport, Barnstaple, EX32 0HU

Walk-in-centre, 31 Sidwell Street, EX4 6NN

Children's Hospice South West, Little Bridge House, Redlands Road, Fremington, Barnstaple, EX31 2PZ

Franklyn Hospital, Chiropody Unit, Franklyn Drive, Exeter, EX2 9HS

Oakwell, Lyiddicleave, Bickington, Barnstaple, EX31 2JZ

GP Practices

Bow Temporary Health Centre,

Crediton, EX17 6EY

Caen Medical Centre, Braunton, North Devon, EX33 1LR

Litchdon Medical Centre, Landkey Road, Barnstaple EX32 9BZ

South Molton Health Centre, 9-10 East Street, South Molton, Devon, EX36 3BZ

Brannam Medical Centre, Brannam Square, Kiln Lane, Barnstaple EX32 8QB

Fremington Medical Centre, 11/13 Beards Road, Fremington, Barnstaple EX31 2PG

Lynton Resource Centre, Lee Road, Lynton EX35 6BP

Wallingbrook Surgery, Back Lane, Chulmleigh EX18 7DL

Boutport Medical Centre, 110 Boutport Street, Barnstaple EX31 1TD

Hartland Surgery, 66 The Square, Hartland, Bideford EX39 6BL

Northam Surgery

Bay View Road, Northam, Bideford, Devon, EX39 1AZ

Willand Road, New Primary Care Centre

Cullompton, EX15 1FE

Bull Meadow Site, Bull Meadow Road, ExeterEX2 4JF

Holsworthy Medical Centre, Dobles Lane, Holsworthy EX22 6GH

Queens Medical Centre, 6-7 Queen Street, Barnstaple EX32 8HY

Withycombe Clinic, 89 Withycombe Village Road, Exmouth, EX8 2AA

Bideford Medical Centre, Abbotsham Road, Bideford EX39 3AF

Ilfracombe Medical Centre, St Brannock's Road, Ilfracombe EX34 8EG

Sidmouth Health Centre

Blackmore Drive, Sidmouth

Wooda Surgery, Clarence Wharf, Barnstaple Street, Bideford EX39 4AU

Castle Gardens Surgery, Castle Hill Gardens, Torrington EX38 8EU

Lisburne, 36/38 church Hill, Honiton, EX14 8DB

GP Practices

Axe Valley, Seaton & Sidmouth Area

Axminster Medical Practice

Seaton & Colyton Medical Practice

Sid Valley Practice

Exmouth & Budleigh Salterton Area

Budleigh Salterton HC

Claremont Medical Practice

Haldon House Surgery



Townsend House Imperial Surgery

Raleigh Surgery

Rolle Medical Partnership

Woodbury Surgery

GP Practices

Crediton & Cullompton Area

Bramblehaies Surgery

Chiddenbrook Surgery

The Surgery

College Surgery Partnership

Newcombes Surgery

Blackdown Practice

Exe Valley Practice

Wyndham House Surgery

Bow Medical Practice

Okehampton Medical Centre

Okement Primary Care Centre

Moretonhampstead HC

Honiton & Ottery St Mary Area Coleridge Medical Centre Honiton Surgery

Exeter Cluster A/B Area

Chapel Platt Surgery

Foxhayes Practice

Hill Barton Surgery

Ide Lane Surgery

Pinhoe Surgery

St Thomas Medical Group

Topsham Surgery

Westbank Practice

Barnfield Hill Surgery

ISCA Medical Practice

Mount Pleasant HC

Southernhay House Surgery

St Leonard's Practice

Clock Tower Surgery

Heavitree Health Centre

South Lawn Medical Practice

Whipton Surgery

Wonford Green Surgery

Tiverton Area

Castle Place Practice

Clare House

Sampford Peverell Surgery

Bampton Surgery

Witheridge Medical Practice

4 Roles and Responsibilities

This policy will apply to all staff, patients, visitors, contractors and other persons who enter the owned or rented buildings or grounds of Northern Devon Healthcare NHS



Trust for any purpose whatsoever. Responsibility for implementing this policy rests with the Chief Executive. Day to day responsibility for implementation rests with Directors and Managers.

4.1 Role of the Chief Executive

Ultimate responsibility for implementing this policy rests with the Chief Executive of Northern Devon Healthcare NHS Trust.

4.2 Role of Directors and Managers

All Directors and Managers are responsible for:

Day to day implementation of the policy.

Informing new staff of the policy, via local induction.

4.3 Role of All Staff

Northern Devon Healthcare NHS Trust sincerely encourages its employees to refrain from smoking outside the times and circumstances set out in this policy, both in their own interest and as representatives of a major public body, whose purpose it is to improve health. However, this falls outside the scope of this policy.

All NHS staff should set an example of good practice to the public with regard to ‘no smoking’. Smoking on Trust premises is not permitted under the following circumstances:

In or on any buildings or grounds, owned or leased by the Trust, including car parks, entrances and courtyards.

In vehicles used for Trust business.

In staff-owned vehicles when on Trust grounds.

In paid time or identifiable as staff (uniform or ID badges). For clarity, uniforms are not worn unless completely covered by other clothing, and, Trust identity badges are not displayed, or

Where they can be readily seen from any entrance to any building or grounds owned and/ or managed by the Trust.

All staff have a duty to uphold the Trust’s Smoke free policy. Trust policy states that there is to be no smoking on Trust premises or on Trust grounds by staff, patients, contractors or any other visitors to the organisation, other than in the relevant and clearly designated areas.

4.4 Role of the Facilities Department, including Tenders and Contractors

To ensure that everyone entering Northern Devon Healthcare NHS Trust sites understands that smoking is not allowed in the buildings and grounds, clear “Smoke Free” and “No Smoking” signs will be on display at the entrances of all Trust premises. The Facilities Department are responsible for ensuring signs are visible and maintained.

With regards to Tenders and Contractors from outside employers the Facilities Department will ensure that all tenders for work with the Northern Devon Healthcare NHS Trust will stipulate compliance with the policy as a



contractual condition, including that all contractors working on Trust sites will meet the policy requirements.

4.5 Role of Human Resources

The Human Resources Team are responsible for ensuring that all Trust job advertisements and selection interviews will include reference to the Smoke free Policy and indicate that compliance will be contractual.

4.6 Role of Occupational Health

The Northern Devon Healthcare NHS Trust will actively support any member of staff who wishes to stop smoking. Occupational Health will assist with the delivery of information about the smoke free policy and advice on resources available to assist with quitting smoking give, including signposting staff onto the stop smoke service run by the Health promotion team.

Occupational Health will support managers in their efforts to ensure that all staff adhere to the policy.

Managers may refer members of their staff who are having difficulty in complying with the policy.

Individual members of staff may self-refer to Occupational Health for information, advice and support in relation to smoking cessation issues.

4.7 Stop Smoking Service

The Stop Smoking Service, is available for any staff, patients or visitors who need help or encouragement to stop smoking. It is accessible on either an individual or group basis and includes nicotine replacement therapies. This is run by the Health Promotion Team and there are smoking advisors regularly available and can be contacted on:

National number: 0800 169 0 169

North Devon & Central Devon number: 01884 836024

Website: www.gosmokefree.nhs.uk

4.8 Role of Communications

The Communications Department is responsible for ensuring that the Trust’s public website and intranet site, and relevant patient information leaflets hold clear information regarding the Trust’s Smoke free Policy together with supporting guidance for anyone wishing to stop smoking.

4.9 Role of Patients, Public and Visitors

Smoking is not permitted by patients or members of the public on the Trust’s premises under the following circumstances:

In or on any buildings or grounds, owned or leased by the Trust, including car parks, entrances and courtyards, will be asked to stop smoking or leave the Trust site.

In private vehicles in car parks or grounds, owned or leased by the Trust.


http://www.gosmokefree.nhs.uk/


Patients and Visitors will be asked to comply with the Trust’s Smoke free policy.

Patients will be advised of this policy on admission via communication methods such as the website and patient information leaflets. Coming into hospital presents many patients with an ideal opportunity to stop smoking. The Trust is committed to providing practical help, support and advice to patients who wish to take advantage of this opportunity. Patient information leaflets will be updated to reflect this advice.

On admission, all patients will have their smoking status recorded using the admission procedure and be referred to the cessation service where appropriate. This will include consideration of the use of nicotine replacement to treat withdrawal symptoms if patient does not wish to consider quitting. See Appendix A.

All staff visiting or treating service users in their own homes are entitled to the same level of protection as those working in Trust premises.

Prior to the initial visit service users will be made aware of the Trust’s ‘no smoking arrangements’ and requested to ensure that the patient and/or other occupants provide a smoke free room and do not smoke during the visit.

5 Implementation of this smoke free policy

All staff have a duty to uphold the Trust’s Smoke free policy.

This smoke free policy states that there is to be no smoking on Trust premises or on Trust grounds by staff, patients, contractors or any other visitors to the organisation, other than in the relevant and clearly designated areas.

The Trust is extending the smoke free environment covered to not only all of its buildings and enclosed areas, but also its land and grounds. CCTV and an intercom will be placed in the front entrance to North Devon District Hospital.

Responsibility for implementing this policy rests with the Chief Executive. Day- to-day responsibility for implementation lies with directors and managers.

Those who wish to stop smoking will be helped to access individual or group support and nicotine replacement therapies as appropriate through the Stop Smoking Service and/or Occupational Health.

On admission, all patients will have their smoking status recorded using the admission procedure and be referred to the cessation service where appropriate.

To ensure that everyone entering Northern Devon Healthcare NHS Trust sites understands that smoking is not allowed in the buildings and grounds;

Clear signage will be on display at all entrance areas, indicating that smoking at entrances and exits by staff, patients or visitors will not be tolerated.

All Staff will be reminded of how the policy relates to their use of vehicles.

All tenders and contractors with the Northern Devon Healthcare NHS Trust will stipulate adherence to the policy as a contractual condition. Existing contracts will be modified as soon as possible.



All patients will be advised of the new policy on admission to the Northern Devon Healthcare NHS Trust premises.

GP practices will also be informed of the policy.

Existing patients will also be addressed through a series of information sessions, with the support of stop-smoking specialists and counselling as appropriate.

Job advertisements will include reference to the non-smoking policy and indicate that the adherence will be contractual.

Training will be offered to staff in advising patients, visitors etc of the policy, as requested.

5.1 Nicotine Replacement Therapy Support

The use of nicotine replacement to prevent symptoms of withdrawal and increased access to smoking cessation advice will be trialled, initially, on surgical elective admissions as part of the enhanced recovery programme. Patients will be seen at pre-operative assessment and smoking status recorded. They will be offered and have prompt access to the smoking cessation service.

If requesting nicotine replacement therapy for withdrawal only, this will be prescribed according to the formulary. The trial will be assessed at six months to review success and determine how it is extended out to emergency patients also. See Appendix A.

Maternity patients are already offered this at booking and the initiative will continue.

6 Breaches of the Policy

The Trust will adopt a zero tolerance to breaches of this policy.

Standard Trust policy and procedures, which can include disciplinary action, will apply to staff.

Members of the public who ignore this policy will be asked to stop smoking and, if necessary, leave the premises and site.

Further encouragement to stop smoking will be given for those patients breaching the Smoke free Policy. The Trust may, as a last resort, withdraw services/ care from patients refusing to comply with the Smoke free Policy.

Staff who fail to comply with the Trust policy should be interviewed by their line manager and referred to Occupational Health for support and advice as appropriate.

Should an individual or group of individuals continue to infringe this policy the manager may invoke disciplinary procedures as a means of encouraging adherence to Trust policy.

6.1 Surveillance of the Front Entrance

It is common for patients and visitors to smoke at the front entrance of the North Devon District Hospital. This is usually initiated by the individuals without discussion with staff. Challenging of these people has led to violence and aggression episodes towards staff. To this end, CCTV and an intercom



will be placed in the front entrance. Smokers will be asked to extinguish their cigarettes, this may be verbally, via the smoke free cards or the intercom.

Any acts of violence and aggression will be reported and, if necessary, the site Police Officer will be called.

6.2 Surveillance of the Maternity Unit Entrance (North Devon District Hospital)

Smokers will be asked to extinguish their cigarettes, this may be verbally, or via the smoke free site cards. Any acts of violence and aggression will be reported and if necessary, the site Police Officer will be called.

Future consideration will be given to the installation of CCTV cameras in this area if the situation continues to be a problem.

7 The Development of the Policy

7.1 Prioritisation of Work

A requirement was identified to improve assurance of the smoke free policy.

7.2 Document Development Process

As the author, the Medical Director is responsible for developing the policy and for ensuring stakeholders have been consulted with. Draft copies were circulated for comment before approval was sought from the relevant committees.

7.3 Equality Impact Assessment

The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. An Equality Impact Assessment has been undertaken and there are no adverse impacts. There is a positive impact for pregnancy, maternity and breastfeeding (see Appendix B).

8 Consultation, Approval and Ratification Process

8.1 Consultation Process

The author consulted widely with stakeholders, including:

Public Health Team

Occupational Health

Facilities directorate

Communications

Corporate Governance

Human Resources

Learning and Development

Staffside policy group



Health and Safety Committee

Clinical Services Executive Committee

Trust Board

Consultation took the form of a request for comments and feedback via email and committee presentation. Hard copies were available on request.

8.2 Policy Approval Process

Initial approval of the policy was gained from the Executive Team in December 2008 and the Clinical Governance Committee in February 2009.

Final approval was given at the Clinical Services Executive Committee meeting in February 2009.

8.3 Ratification Process

The policy was ratified by the Trust Board in March 2009.

9 Review and Revision Arrangements including Document Control

9.1 Process for Reviewing the Policy

The policy will be reviewed every three years. The author will be sent a reminder by the Corporate Governance Manager four months before the due review date. The author will be responsible for ensuring the policy is reviewed in a timely manner and that the reviewed policy is approved by the Trust Board.

All reviews will be recorded by the author in the Document Control Report.

9.2 Process for Revising the Policy

In order to ensure the policy is up-to-date, the author may be required to make a number of revisions, e.g. committee changes or amendments to individuals’ responsibilities. Where the revisions are minor and do not change the overall policy, responsibility for the revisions will be held by the Medical Director. Significant revisions will be presented to the Trust Board for approval.

All revisions will be recorded by the author in the Document Control Report.

9.3 Document Control

The author will comply with the Trust’s agreed version control process, as described in the organisation-wide Guidance for Document Control.

10 Dissemination and Implementation

10.1 Dissemination of the Policy

After approval by the Trust Board, the author will provide a copy of the policy to the Corporate Governance Manager to have it placed on the Trust’s intranet.



The policy will be referenced on the home page as a latest news release. Information will also be included in the weekly Chief Executive’s Bulletin which is circulated electronically to all staff. An email will be sent to senior management to make them aware of the policy and they will be responsible for cascading the information to their staff. In addition, staff will be informed that this policy replaces any previous versions.

10.2 Implementation of the Policy

Line managers are responsible for ensuring this policy is implemented across their area of work. The Medical Director will be available for advice on any aspect of this policy.

11 Document Control including Archiving Arrangements

11.1 Library of Procedural Documents

The author is responsible for recording, storing and controlling this policy.

Once approved, the author will provide a copy of the current policy to the Corporate Governance Manager so that it can be placed on the Trust’s intranet site. Any future revised copies will be provided to ensure the most up-to-date version is available on the Trust’s intranet site.

11.2 Archiving Arrangements

All versions of this policy will be archived in electronic format within the Medical Director’s policy archive. Archiving will take place by the Medical Director once the final version of the policy has been issued.

Revisions to the final document will be recorded on the Document Control Report. Revised versions will be added to the policy archive held by the Director of Development.

11.3 Process for Retrieving Archived Policy

To obtain a copy of the archived policy, contact should be made with the Medical Director.

12 Monitoring Compliance With and the Effectiveness of Procedural Documents

12.1 Standards/ Key Performance Indicators

The effectiveness of the policy will be monitored through complaints, incident forms, referrals to stop smoking services, observation and ad hoc audit.

12.2 Process for Monitoring Compliance and Effectiveness

Monitoring compliance with this policy will be the responsibility of the Medical Director. It will be reported to the Learning from Patient Experience Group (LPEG). Where non-compliance is identified, support and advice will be provided to improve practice.

Staff who do not comply with the policy will be interviewed by their line manager and referred to the Smoking Cessation Advisor and/ or Occupational Health for support and advice as appropriate. Should an individual or group



of individuals infringe this policy the manager may invoke disciplinary procedures as a means of encouraging adherence to the policy.

13 References

Smoke Free Regulations 2007

Health & Safety at Work Act 1974

Management of Health and Safety at Work Regulations 1999

NHS Smokefree | smokefree.NHS.uk

14 Associated Documentation

Disciplinary Policy

Health and Safety policy

Managing Violence and Aggression Policy

Uniform Policy


http://smokefree.nhs.uk/?&gclid=CMyekJi8sa4CFYgmtAodkRFROQ







Appendix A: Smoking Admission Protocol

Patient Admission:

Assess and record the smoking status of the

patient.

NO Non Smokers

No further action required.

Ask Patient:

Is the patient a Smoker?

YES

Advise Patient:

“It is important to stop smoking and it will help

in your recovery”

Access Patient Smoking Status:

Is the patient ready to stop smoking?

NO

YES

Ask Patient:

If they would like to see the Smoking Cessation

Advisor.

NO Ask Patient:

If they would like NRT to alleviate withdrawal.

NO Support Patient: Offer patient the ‘need

help giving up smoking?’ leaflet and

referral card.

YES YES

Support Patient: Fax referral form or

phone Smoking Cessation Advisor on

0845 155 8080.

Support Patient: Arrange for prescribing

of NRT according to the North Devon and area joint formulary.

NRT = Nicotine Replacement Therapy .


Appendix B: Equality Impact Assessment Screening Form

Equality Impact Assessment Screening Form

Title Smoke free Policy

Author Alison Diamond, Medical Director

Directorate Medical

Team/ Dept.

Medical Directorate

Document Class

Policy

Document Status

REview

Issue Date

February 2012

Review Date

TBC

1 What are the aims of the document?

This policy is fundamental to the Trust’s desire to play an exemplary health promotion role as a health care organisation supporting a smoke free environment, for the benefit of all patients, staff and visitors. This document sets out the agreed hospital protocols for inpatients, outpatients, visitors and staff who smoke. It also sets out the specialist smoking cessation support available to patients and staff and promotes the use of Nicotine Replacement Therapy.

2 What are the objectives of the document?

The Northern Devon Healthcare NHS Trust as an employer has a duty to reduce risk in the workplace and look after the welfare of its staff and, as a provider of health care services, the Trust has a core responsibility to improve people’s health and opportunity to promote good public health. Smoking is the biggest single cause of ill health and premature death in the UK and second hand smoke – breathing other people’s smoke – has now been shown to cause lung cancer and heart disease in non smokers, as well as many other illnesses and minor conditions.

Implementation of this policy will:

Protect and improve the health of staff.

Protect and improve the health of patients, visitors and contractors.

Motivate and support smokers who wish to quit by providing smoking cessation advice with minimum costs to the individual.

Protect both smokers and non-smokers from the danger to their health of exposure to second hand smoke.

Set an example to other employers and workforces, particularly in health related locations.

Demonstrate the Trust’s leadership role in public health and health provision by arranging for Trust buildings, properties and vehicles to be ‘smoke-free’ and by requiring staff not to smoke while in paid working time or in an identifiable NHS or Northern Devon Healthcare NHS Trust uniform.

Comply with Department of Health legislation and guidance.



3 How will the document be implemented?

The policy will be communicated to staff patients and the public via a number of means e.g. trust website, signs and posters, induction, patient information literature.

4 How will the effectiveness of the document be monitored?

Monitoring compliance with this policy will be the responsibility of the Medical Director. It will be reported to the Learning from Patient Experience Group (LPEG).

5 Who is the target audience of the document?

This policy applies to all staff, patients, contractors, visitors and other persons who enter the Northern Devon Healthcare NHS Trust owned, rented or leased buildings, enclosed areas or grounds for any purpose whatsoever.

6 Is consultation required with stakeholders, e.g. Trust committees and equality groups?

Yes

7 Which stakeholders have been consulted with?

Public Health Team Occupational Health Facilities directorate Communications Corporate Governance Human Resources Learning and Development Staff side policy group Trust Board

8 Equality Impact Assessment

Please complete the following table using a cross, i.e. X. Please refer to the document “A Practical Guide to Equality Impact Assessment”, Appendix 3, on Tarkanet for areas of possible impact.

Where you think that the policy could have a positive impact on any of the equality group(s) like promoting equality and equal opportunities or improving relations within equality groups, cross the ‘Positive impact’ box.

Where you think that the policy could have a negative impact on any of the equality group(s) i.e. it could disadvantage them, cross the ‘Negative impact’ box.

Where you think that the policy has no impact on any of the equality group(s) listed below i.e. it has no effect currently on equality groups, cross the ‘No impact’ box.

Equality Group Positive Impact

Negative Impact

No Impact

Comments

Age X

Disability X

Gender X




Gender reassignment

X

There are four new equality groups added to this updated EIA. Please consider your policy contents and complete for these.

Human Rights (rights to

privacy, dignity, liberty and non

degrading treatment)

X

Marriage and civil

partnership X

Pregnancy, maternity and breastfeeding

X Positive benefits to mother, unborn child and child.

Race / Ethnic Origins

X

Religion or Belief

X

Sexual Orientation

X

If you have identified a negative discriminatory impact of this procedural document, ensure you detail the action taken to avoid/reduce this impact in the Comments column. If you have identified a high negative impact, you will need to do a Full Equality Impact Assessment, please refer to the document “A Practical Guide to Equality Impact Assessments”, Appendix 3, on Tarkanet. For advice in respect of answering the above questions, please contact the Equality and Diversity Lead.

9 If there is no evidence that the document promotes equality, equal opportunities or improved relations, could it be adapted so that it does? If so, how?

No

Completed by:

Name Alison Diamond Designation Medical Director Trust Northern Devon Healthcare NHS Trust Date February 2012