Smoke free Policy
Document Control
Version:
Ratified by:
Date ratified
Policy sponsor:
Name of policy originator/author:
Name of responsible committee/individual:
Date issued:
Review date:
Target audience:
3
Clinical Governance Committee
15 January 2010
Director of Nursing, Midwifery &
Patient Experience
Assistant Director of Quality
Clinical Governance Committee
To be issues when smoke shelter
in place
January 2011
Trust wide
Smoke free Policy 2010
Smoke free Policy
Contents page
CONTENTS
1
2
3
3.1
3.2
3.3
3.4
3.5
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Introduction
Purpose
Duties
Director of Nursing, Midwifery & Patient Quality
Trust employees
Senior management
Security team
Patient Concierge
Definitions
Achieving a smoke free site
Exceptional circumstances
Home visits
Non compliance with the policy
Patient support for giving up smoking
Staff support for giving up smoking
Staff non compliance with policy
Responsibility for policy development
Identification of stakeholders
Equality Impact assessment
Consultation and ratification process
Dissemination and Implementation
Policy distribution & Storage
Training
Archiving arrangements
Monitoring
Key performance indicators
Audit
Associated policies
References
Main enforcing legislation
PAGE
3
4
4
4
4
5
6
6
6
6
6
7
7
7
7
8
8
8
8
8
9
9
9
9
9
9
9
9
10
10
Appendix A
Appendix B
Appendix C
Appendix D
Equality & Diversity checklist
Checklist for review & ratification
Training needs analysis
Audit tool for compliance to policy
11
13
16
18
Liz Edwards, Assistant Director of Quality 2010
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Smoke free Policy 2010
1. Introduction
This policy sets out the Liverpool Women’s NHS Foundation Trust’s approach to
establishing a smoke free environment. The basis for the policy is grounded in the
principle that all healthcare organisations should actively promote a healthy
environment for patient, staff and visitors.
On July 1st 2007 legislation was introduced to ensure that all enclosed areas and work
places became ‘smoke free’ The Trust recognises the impact that smoking in the
areas surrounding the building has on patients, visitors and staff. With this in mind,
the continued policy, introduced on 1st January 2006 enforces a ban on smoking in the
grounds and car park areas.
Despite all efforts to maintain a smoke free environment, the Trust has encountered
problems relating to non compliance by patients and visitors who continue to smoke in
the grounds despite notices and verbal requests to refrain from smoking. This has
resulted in a number of complaints and concerns raised about this non compliance
and its effects on patients, visitors and staff.
In response to patient, visitor and staff surveys, the decision has been taken to
reintroduce a smoke shelter as a designated smoking area for patients and visitors
only.
Almost one-third of pregnant women in England smoke (1). Babies born to women who
smoke are on average 200 grams lighter than babies born to comparable non-smoking
mothers. Recent research suggests that cigarettes can impede the flow of blood in the
placenta, which in turn restricts the amount of nutrients that reach the foetus (2).
Non-smoking women exposed to other people’s tobacco smoke during pregnancy are
more likely to have lower weight babies. Babies born to non-smoking women whose
partners smoked weighed less than babies born to non-smoking couples (3). Moreover,
women exposed to second-hand smoke in the workplace are also affected (4). A review
of the evidence concluded that on average, infants born to women exposed to secondhand smoke during pregnancy are 40-50g lighter than those born to women who are not
exposed.
The latest figures from the NHS Stop Smoking Services (5) report that during the
period April 2008 to March 2009, 18,928 (17,917 in 05-06) pregnant women set a quit
date through the Stop Smoking Services. The number of pregnant women who
reported having successfully quit at the 4 week follow up was 8,641 (9,592 in 05-06),
giving a 46% quit rate (54% in 05-06). The number of successful pregnant quitters has
therefore decreased.
Currently 17% of pregnant women who have admitted to smoking at booking
appointment have stopped smoking at time of delivery (2005-2006 23%, 2006-2007
22.9%, 2007-2008 16.5%)
Following the white paper SMOKING KILLS (6), the NATIONAL SERVICE
FRAMEWORK FOR CORONARY HEART DISEASE (7) and the increasing support
for the smoke free agenda, for Primary Care and NHS Trusts to build on this success
and to make their smoking policies more explicit. An estimated 28.8 per cent of the
workforce in Liverpool’s workplaces smoke , 66% of all smokers want to give up (8)
Liz Edwards, Assistant Director of Quality 2010
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Smoke free Policy 2010
The Liverpool Women’s NHS Foundation Trust’s policy is that smoking is not
permitted in or on any of its grounds, premises or vehicles, other than the designated
smoke shelter situated opposite the main reception entrance.
The Trust is committed to ensuring a safe and healthy environment for its employees
and service users and acknowledges that breathing other people’s tobacco smoke is
both a public health hazard and a welfare issue. The Trust recognises its duties under
the Health and Safety At Work Act 1974, and the Management of Health and Safety at
Work Regulations 1999 to do everything possible to protect the health of its workforce
and service users from the effects of second hand smoke.
The Trust aims to be an exemplar of good health practice. Further, the Trust aspires to
enable all patients and employees to be free of tobacco addiction and will put
appropriate support mechanisms in place to achieve this.
2.
Purpose
This smoke free policy aims to:
• Provide a smoke free environment for all patients to optimise their recovery
• Protect visitors including babies and young children
• Provide a smoke free environment for all staff and to guarantee all individuals the
right to work in air free of tobacco smoke.
• Support patients and staff to stop smoking
3.
Duties
3.1 Director of Nursing, Midwifery & Patient Quality
Has an overarching responsibility to ensure this policy is adhered to
3.2 Trust employees
All employees have a duty to comply fully with the policy:
•
Employees who smoke and do not wish to stop smoking must not smoke in or on
any of the Trust’s premises and grounds.
•
Staff will only be able to go off site to smoke during designated breaks. Where
this would cause significant distress, advice should be sought from the
Occupational Health Department.
•
Staff will be expected to set a good example to patients and the public. They will
not smoke in view of patients, clients or the public in uniform or when wearing
name badges or at any time when undertaking duties on behalf of the Trust.
•
Smoking is not permitted in Trust vehicles. All vehicles used for Trust business
must be smoke free.
Liz Edwards, Assistant Director of Quality 2010
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Smoke free Policy 2010
•
No Trust staff working in the community will be allowed to smoke whilst on duty,
irrespective of their location (this also includes cars being used during business
hours).
•
All staff have a role as health educators particularly those involved in clinical care
and should lead by example by being positive role model to patients.
•
All Trust staff are encouraged to inform patients, relatives, visitors and other Trust
staff, if they are seen smoking in or on any of the Trust’s grounds or premises, that
the Trust has a smoke-free policy and that smoking is not permitted anywhere, at
any time.
•
Staff entering patients on to the hospital information system (Meditech) will be
required to verbally inform patients of the trust policy, politely reminding them that
the policy also applies to their visitors and advising them of stop smoking services
available to them.
•
It is not expected that staff should put themselves at any risk of abuse by someone
who is smoking by doing this. It is therefore suggested that people’s attention is
merely drawn to the large number of no smoking signs that will be put up
throughout Trust buildings and in the grounds.
•
Should any member of staff have a complaint made against them for pointing out
the Trust’s smoke-free policy to anyone who is smoking, they will have the Trust’s
full support for taking such action, which will be in compliance with the policy.
•
Staff members should report any problems with exposure to tobacco smoke to
their line manager.
Staff should request a health assessment if they think they may be at risk. Those with
a pre existing condition such as asthma should be extremely vigilant (for Occupational
Health see section 13).
3.3 Senior management
Managers and supervisors have a responsibility to ensure that staff, patients, visitors,
contractors and other persons are aware of and adhere to the policy within the
premises and/or services under their management control.
Managers will fully support any employee wishing to stop smoking by providing
adequate and reasonable time during normal working hours for them to access
counselling/treatment (see Section 10).
Disciplinary action will be taken for persistent breaches of the policy.
Liz Edwards, Assistant Director of Quality 2010
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Smoke free Policy 2010
3.4 Security team
The security team will support staff in enforcing the Smoke free policy by directly
challenging patients and visitors who smoke in all areas of the Trust, requesting that they
use the designated smoking shelter.
The security team will challenge any staff who do not comply with the smoke free policy
3.5 Patient Concierge
The Patient Concierge will play a pivotal role in enforcing the smoke free policy in
particular at the main entrance area
4 Definitions
4.1 Grounds
Grounds are the perimeter of land around Trust buildings such as car parks,
courtyards, and gardens etc.
4.2 Premises
Premises are any owned or rented building, which are used by the Trust for whatever
purpose.
4.3 Trust Vehicles
All vehicles owned or leased as part of the Trust fleet but not cars leased to individual
members of staff.
4.4 Smoke Shelter
A specifically designed smoke shelter will be located opposite the main reception
entrance, in line with Health & Safety Regulations. The shelter is the only designated
area on site where visitors and patients only can smoke.
5 Achieving a Smoke Free Environment
•
•
•
•
•
•
•
•
The Trust grounds and premises will be NO SMOKING AREAS at all times, with
the exception of designated smoking areas for patients and visitors.
All patients, relatives, visitors and staff must comply with the policy.
Tobacco or smoking materials of any description will not be sold in or on any of the
Trust grounds or premises.
Smoke alarms will be in place in and around buildings which will be activated by
cigarette smoke.
The Trust will support smokers who wish to give up smoking via the provision of
Liverpool Stop Smoking Services – (see section 10)
The Trust will encourage and support ex smokers in maintaining their non-smoking
behaviour.
The Trust will work with its suppliers to raise awareness of the dangers of tobacco
smoke and to encourage and support them to be smoke free.
The Trust will publicise a smoke free policy as normal practice.
Liz Edwards, Assistant Director of Quality 2010
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Smoke free Policy 2010
6 Exceptional Circumstances
The Trust recognises that there may be exceptional circumstances involving a small
number of individual patients where discretion regarding smoking may be exercised
eg. end stages of life, bereavement. Such cases will be treated on an individual basis.
Permission to grant an exception will rest with the line manager or matron, and will be
formally recorded within the Care Plan. When special arrangements are made
Operational Services and appropriate Bleep Holders should be informed.
7 Home Visits
The Trust recognises that some staff may be exposed to tobacco smoke when
working elsewhere outside of the Trust’s control such as client’s homes, etc. In all
cases, clients will be informed of the requirement to eliminate staff’s exposure to
tobacco smoke, especially in enclosed spaces.
Letters will be sent out to all patients who routinely receive home visits, advising them
of the Trust’s smoke free status, and requesting that a smoke free room be available
for the duration of the visit. If the patients feel unable to comply with this, then an
alternative clinic appointment will be offered. Staff will also be encouraged to politely
ask clients not to smoke in their presence and remind them of the Trust policy.
8 Non Compliance with the Policy
Where a patient, relative/carer or visitor persistently refuses to refrain from smoking
when asked to do so by a member of Trust staff and the situation becomes heated
then a Trust incident form should be completed. In case of verbal or physical abuse
the member of staff should refer to the Zero Tolerance Policy.
9 Patient Support for Giving up Smoking
In order to support all patients affected by this policy, the following help is being
provided:
The Trust will offer support for maternity patients via the Liverpool Stop Smoking
Service (SUPPORT). This will be in the form of either home or inpatient visits, or clinic
appointments if preferred. Patients can ask their midwife, Nurse, GP, Health Visitor or
Pharmacist for a referral, or they can directly contact the Stop Smoking midwife, on
07887581749 (Monday am. or Wednesday pm), to access this service.
The Stop Smoking midwife for patients residing in the Sefton area can be contacted
on 0786 755 4793.
Advice and support will be offered to patients including the following:
•
•
Counselling
NRT (Nicotine Replacement Therapy - subject to certain medical conditions)
Non maternity patients will be offered the services of ‘Fagends’.
The Roy Castle Fag Ends Community Stop Smoking Service (RCFE) is commissioned
by Liverpool Primary Care Trust (PCT) to provide the stop smoking service across
Liz Edwards, Assistant Director of Quality 2010
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Smoke free Policy 2010
Liverpool and by Knowsley PCT to provide the stop smoking service for Knowsley. Staff
will make patients aware of this service to support patients who want to stop smoking.
10 Staff Support for Giving Up Smoking
In order to support all staff affected by this policy, the following help is being provided:
The Trust will offer staff support via the Liverpool Stop Smoking Service (SUPPORT).
Staff can contact the Stop Smoking midwife, on ext 4305 (Monday am. or Wednesday
pm), or 0788 756 1749, to access this service. The Stop Smoking midwife for Sefton
and can be contacted on 0786 755 4804. . Staff can also contact the Occupational
Health department for help and advice on ext 4071.
Advice and support will be offered to staff including the following:
•
Time off to attend Stop Smoking Support Sessions should be agreed in liaison with
the line manager. This may require attendance at several sessions, during which
hypnotherapy and acupuncture maybe on offer.
•
Cost of NRT on prescription for up to eight weeks
•
Support from ‘Fagends’, see previous page.
11 Staff Non-Compliance with this Policy
An initial breach of the policy will be dealt with informally with Occupational Health
support to allow the individual employee to stop smoking during working hours.
Subsequent breaches of the policy may lead to formal disciplinary action being taken
in line with the Trust’s Disciplinary and Health and Safety Procedures; particularly if
the offer of support to stop smoking has been rejected.
12 Responsibility for Policy Development
It is the responsibility of the Assistant Director of Quality to develop and regularly review
this policy in line with the process outlined in “An Organisation-wide Policy for the
Development and Management of Policy Documents“.
13
Identification of stakeholders
This includes members of the Trust Risk Management Committee, Health & Safety
Committee, all clinical and non clinical managers, Hotel Services and Security
contractors, Patient Involvement Group
14
Equality Impact Assessment
This policy has been subject to and Equality Impact Assessment and is not anticipated to
have an adverse impact on any group (see appendix 1).
15
Consultation and Ratification Process
This policy has been circulated to members of the Clinical Governance Committee, Trust
Risk Management Committee and Patient Involvement group who have been consulted
Liz Edwards, Assistant Director of Quality 2010
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Smoke free Policy 2010
regarding this policy. This policy has also been posted onto the news section of the Trust
Intranet in order to gather comments from any interested parties. A message has been
posted to all users to raise awareness of the new draft policy on the site and an email link
has been provide for staff to respond to the Assistant Director of Quality. The Clinical
Governance Committee will ratify this policy following wide consultation throughout Trust.
16.
Dissemination and Implementation
Following ratification the Assistant Director of Quality will forward this policy to the Intranet
management lead and distribute it to directorate and departmental managers for
dissemination to their staff. This policy shall be presented as agenda items at directorate
and department meetings and show evidence to reflect that all staff has been informed of
the implementation of this policy and how to access it. This will be discussed at Trust
Induction
17.
Policy Distribution and Storage
This policy will be stored on the Intranet in the Trust policy database and accessed via the
Liverpool Women’s NHS Foundation Trust Policies and Procedures on the website
(Intranet).
18.
Training
Training to raise awareness of the Smoke free policy will be provided on appointment of
Directorate and Departmental staff. (see appendix 2)
19.
Archiving Arrangements
All superseded versions of this policy have been retained for future reference and
archived in the Trust policy archiving files on the Intranet accessed via the Liverpool
Women’s NHS Foundation Trust Policies and Procedures section of the Intranet.
Retrieving archived versions of this policy will be via the Deputy Director of IM&T.
20.
Monitoring
The Assistant Director of Quality will identify key performance indicators associated with
the implementation of this policy including the minimal requirements identified in the
NHSLA General Standards.
An audit tool including the key performance indicators and minimal requirements of the
NHSLA General Standards will be commissioned by the Assistant Director of Quality and
agreed by the Trust Risk Management Committee (Appendix 4 ).
The recommendations and associated action plan developed by each
directorate/department from the completion of the audit tool will be monitored by the Trust
Risk Management Committee. A Trust-wide report including recommendations, action
plans and ongoing monitoring arrangements will be compiled by the Assistant Director of
Quality and presented to the Trust Risk Management Committee.
21
•
22.
Key Performance Indicators
Annual audit of compliance to ‘Smoke free policy Tool” (Appendix 4 )
Audit
Liz Edwards, Assistant Director of Quality 2010
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Smoke free Policy 2010
The Trust Risk Management Committee will monitor compliance with this policy through
the audit of “Complaint Management Policy Tool” associated recommendations and
action plan (Appendix 4)
23.
•
•
•
•
•
•
•
Associated Policies
Incident Reporting Policies
Health and Safety Policy
Disciplinary Procedure
Policy for With-holding of Treatment
Zero Tolerance Policy Trust Risk Management Strategy
Risk assessment Policy
An Organisation wide policy document for the management and development of
policy documents
•
24.
References
1 ASH (2004) Factsheet No 7: Smoking, Sex And Reproduction. London
2 Larson, L.G. (2002) Stereological Examination Of Placentas From Mothers Who
Smoke During Pregnancy. Am J of Obstet & Gynacol Vol 186
3 Hruba, D, Katchlik, P. (2000) Influence Of Maternal Active And Passive Smoking
During Pregnancy On Birthweight In Newborns Central European Journal of
Public Health Vol 8 249-52
4 Misra, P, Nguyen, R. (1999) Environmental Tobacco Smoke And Low Birth Weight:
A Hazard In The Workplace? Environmental Health Perspectives Vol 107 pp
897-90
5 Statistics on NHS Stop Smoking Services in England, April 2005 to March 2006,
the Information Centre.2006
6 Department of Health (1998). Smoking Kills: A White Paper on Tobacco. London:
The Stationery Office
7 Department of Health (2000). Coronary Heart Disease: National Service
Framework for Coronary Heart Disease. London: Department of Health
8 Christakopoulou, S., Dawson, K. (2004) Survey Of Second-Hand Tobacco Smoke
In Liverpool Workplaces A Report For SmokeFree Liverpool Chester.: Jon
Dawson Associates
Enforcing Legislation
Health Act 2006:
a. The Smoke-free (Premises and Enforcement) Regulations,
b. The Smoke-free (Signs) Regulations,
c. The Smoke-free (Exemptions and Vehicles) Regulations,
d. The Smoke-free (Penalties and Discounted Amounts) Regulations
Liz Edwards, Assistant Director of Quality 2010
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Smoke free Policy 2010
Appendix 1
EQUALITY AND DIVERSITY – POLICY SCREENING CHECKLIST
Policy Title: An Organisation Wide Policy for the Development and
Management of Policy Documents
Directorate/Department: Corporate Services
Name of person/s auditing / authoring policy: Assistant Director of Clinical Governance
Policy Content:
•
For each of the following check whether the policy under consideration is sensitive to people of a different age, ethnicity,
gender, disability, religion or belief, and sexual orientation?
•
The checklist below will help you to identify any strengths and weaknesses of the policy and to check whether it is
compliant with equality legislation.
1. Check for DIRECT discrimination against any minority group of patients:
Action
required
Question: Does the policy contain any statements which may
disadvantage people from the following groups?
Yes
Yes
No
1.0
Age?
X
x
1.1
Gender (Male, Female and Transsexual)?
x
x
1.2
Learning Difficulties / Disability or Cognitive
Impairment?
x
x
1.3
Mental Health Need?
x
x
1.4
Sensory Impairment?
x
x
1.5
Physical Disability?
x
x
1.6
Race or Ethnicity?
x
x
1.7
Religious Belief?
x
x
Sexual Orientation?
x
x
1.8
Resource
implication
Response
Yes
No
2. Check for DIRECT discrimination against any minority group relating to EMPLOYEES:
Action
required
Question: Does the policy contain any statements which may
disadvantage employees or potential employees from any of the
following groups?
Yes
Yes
No
Age?
x
x
2.1
Gender (Male, Female and Transsexual)?
x
x
2.2
Learning Difficulties / Disability or Cognitive
Impairment?
x
x
2.3
Mental Health Need?
x
x
2.4
Sensory Impairment?
x
x
2.5
Physical Disability?
x
x
2.0
Liz Edwards, Assistant Director of Quality 2010
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Resource
implication
Yes
No
11
Smoke free Policy 2010
Race or Ethnicity?
x
x
2.7
Religious Belief?
x
x
2.8
Sexual Orientation?
x
x
2.6
TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING DIRECT DISCRIMINATION = 0
3. Check for INDIRECT discrimination against any minority group of Patient:
Question: Does the policy contain any conditions or requirements
which are applied equally to everyone, but disadvantage particular
people because they cannot comply due to:
Action
required
se
Yes
Yes
No
3.0
Age?
x
x
3.1
Gender (Male, Female and Transsexual)?
x
x
3.2
Learning Difficulties / Disability or Cognitive
Impairment?
x
x
3.3
Mental Health Need?
x
x
3.4
Sensory Impairment?
x
x
3.5
Physical Disability?
x
x
3.6
Race or Ethnicity?
x
x
3.7
Religious, Spiritual belief (including other belief)?
x
x
Sexual Orientation?
x
x
3.8
Resource
implication
Yes
No
4. Check for INDIRECT discrimination against any minority group relating to EMPLOYEES:
Question: Does the policy contain any statements which may
disadvantage employees or potential employees? from any of the
following groups?
Action
required
Yes
Yes
No
Age?
x
x
4.1
Gender (Male, Female and Transsexual)?
x
x
4.2
Learning Difficulties / Disability or Cognitive
Impairment?
x
x
4.3
Mental Health Need?
x
x
4.4
Sensory Impairment?
x
x
4.5
Physical Disability?
x
x
4.6
Race or Ethnicity?
x
x
4.7
Religious, Spiritual belief (including other belief)?
x
x
4.8
Sexual Orientation?
x
x
4.0
Resource
implication
Yes
No
TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING INDIRECT DISCRIMINATION = 0
Equality and Diversity Compliance / Percentage Calculation
Number of ‘Yes’ answers for DIRECT discrimination.
(A) 0
Number of ‘Yes’ for INDIRECT discrimination.
(B) 0
Total answers for POLICY CONTENTS discrimination.
(A+B) 0
Percentage content non compliant
=0
Liz Edwards, Assistant Director of Quality 2010
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Divide 36 x 100
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Smoke free Policy 2010
Appendix 2
Checklist for the Review and Ratification of Policy Documents
To be completed and attached to any document which guides practice when submitted to
the appropriate committee for consideration and approval.
Title of document being reviewed:
1.
2.
4.
5.
Comments
Title
Is the title clear and unambiguous?
Y
Is it clear whether the document is a
guideline, policy, protocol or standard?
Y
Rationale
Are reasons for development of the
document stated?
3.
Yes/No/
Unsure
Y
Development Process
Is the method described in brief?
Y
Are people involved in the
development identified?
Y
Do you feel a reasonable attempt has
been made to ensure relevant
expertise has been used?
Y
Is there evidence of consultation with
stakeholders and users?
Y
Content
Is the objective of the document clear?
Y
Is the target population clear and
unambiguous?
Y
Are the intended outcomes described?
Y
Are the statements clear and
unambiguous?
Y
Evidence Base
Is the type of evidence to support the
document identified explicitly?
Y
Are key references cited?
Y
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Smoke free Policy 2010
Title of document being reviewed:
6.
7.
8.
9.
10
.
Yes/No/
Unsure
Are the references cited in full?
Y
Are supporting documents referenced?
Y
Comments
Approval
Does the document identify which
committee/group will approve it?
Y
If appropriate have the joint Human
Resources/staff side committee (or
equivalent) approved the document?
Y
For production of original
document
Dissemination and Implementation
Is there an outline/plan to identify how
this will be done?
Y
Does the plan include the necessary
training/support to ensure compliance?
Y
Document Control
Does the document identify where it
will be held?
Y
Have archiving arrangements for
superseded documents been
addressed?
Y
Process to Monitor Compliance and
Effectiveness
Are there measurable standards or
Kips to support the monitoring of
compliance with and effectiveness of
the document?
N
Is there a plan to review or audit
compliance with the document?
N
Review Date
Is the review date identified?
Y
Is the frequency of review identified? If
so is it acceptable?
11
.
Overall Responsibility for the
Document
Is it clear who will be responsible for
Liz Edwards, Assistant Director of Quality 2010
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Y
14
Smoke free Policy 2010
Title of document being reviewed:
Yes/No/
Unsure
Comments
co-ordinating the dissemination,
implementation and review of the
document?
Individual Approval
If you are happy to approve this document, please sign and date it and forward to
the chair of the committee/group where it will receive final approval.
Name
Date
Signature
Committee Approval
If the committee is happy to approve this document, please sign and date it and
forward copies to the person with responsibility for disseminating and implementing
the document and the person who is responsible for maintaining the organisation’s
database of approved documents.
Name
Date
Signature
Acknowledgement: Cambridgeshire and Peterborough Mental Health Partnership NHS
Trust
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Smoke free Policy 2010
Appendix 3
TRAINING NEEDS ANALYSIS FOR THE DEVELOPMENT AND MANAGEMENT OF
POLICY APPROVED DOCUMENTS
Please Tick as appropriate
There is no specific training requirements for staff required
There is specific awareness requirements for relevant staff
Corporate Induction
Local Induction
Meetings
Other (state)
There is specific training requirements for staff groups
Please complete the section below of the identified formal training discuss with learning and development department
Staff Group
Tick if
relevant
Frequency
Delivery method e.g.
Formal teaching
e-learning
Handout etc
Executive Directors
Non-Executive
Directors
Senior Managers
Consultant Medical
Staff
Junior Doctors
Nurses
Midwives
ANP
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Clinical Scientists
Specialists allied to
medicine
Health Care
annuitants
Ancillary Staff
Contractors
Please give the source of information that has informed the training requirement i.e.
National Confidential Enquiries/NICE Guidance etc
Please give any additional information impacting on identified staff group training
needs (if applicable)
Complaints investigation training is delivered by the Patient Quality Manager. As
complaints investigation and handling is Directorate led, the training is delivered to
senior staff who are specifically involved in the process as part of their role.
The procedure and policy are discussed at Trust Induction sessions to ensure all staff
are aware of their role in ensuring patients and visitors are able to effectively vice any
concerns
Name:
-----------------------------------------------------------------------------
Signature: ----------------------------------------------------------------------------Liz Edwards, Assistant Director of Quality 2010
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Smoke free Policy 2010
Date:
----------------------------------------------------------------------------
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Appendix 4
Audit of Compliance to Smoke free Policy
Ref
Yes
No
NA
Notes
Smoke free Policy 2010
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