All Trust employees, agency workers and (sub)contractors

Transcription

1 Policy: Dress Code Executive or Associate Director lead Policy author/ lead Feedback on implementation to Dean Wilson, Director Of Human Resources Jane Askew, HR Business Partner Jane Askew, HR Business Partner Document type Policy Document status Final Date of initial draft September 2016 Date of consultation September 2016 Date of verification 21 September 2016 Date of ratification 29 September 2016 Ratified by Executive Directors Group Date of issue 11 October 2016 Date for review 31 August 2019 Target audience Keywords All Trust employees, agency workers and (sub)contractors Dress, code, uniform Policy version and advice on document history, availability and storage This is version 3.0 of this policy and replaces version 2 (March 2009). This version was reviewed and updated as part of an on-going policy document review process. This policy will be available to all staff via the Sheffield Health & Social Care NHS Foundation Trust Intranet and on the Trust s website. The previous version will be removed from the Intranet and Trust website and archived. Word and pdf copies of the current and the previous version of this policy are available via the Director of Corporate Governance. Any printed copies of the previous version (V2) should be destroyed and if a hard copy is required, it should be replaced with this version. 1 P a g e

2 Contents Section Page 1 Introduction 3 2 Scope 3 3 Definitions 3 4 Purpose 4 5 Duties 4 6 Process Personal Hygiene Make up and Finger Nails Jewellery - general Health & Safety Identification Badges Changes to Dress Code Policy Losses and Compensation Non-uniformed staff Non-uniformed staff in direct patient contact Uniformed staff Direct care/housekeeping staff/similar roles Infection Control Hair Jewellery in clinical roles Tattoos Footwear 6.17 Mobile Phones/Bleeps 6.18 No Smoking 6.19 Temporary employees, including students 6.20 Maternity clothing Dissemination, storage and archiving 9 8 Training and other resource implications 9 9 Audit, monitoring and review 9 10 Implementation plan Links to other policies, standards and legislation (associated 10 documents) 12 Contact details References 10 Appendices Appendix A Version Control and Amendment Log 12 Appendix B Dissemination Record 13 Appendix C Equality Impact Assessment Form 14 Appendix D - Human Rights Act Assessment Checklist 15 Appendix E Development, Consultation and Verification Record 17 Appendix F Policy Checklist 18 Appendix G Laundry Guidelines 20 Appendix H - Expected Standards and Reasons 21 2 P a g e

3 1. Introduction This policy has been introduced to protect the safety of patients/ service users and staff by ensuring employees uniform and dress code complies with infection control requirements and health and safety legislation and to ensure that all employees present a professional image. The policy accommodates personal and cultural diversity where this does not compromise the safety of patients or staff, or damage the professional standing of the individual or the Trust. Adjustments to accommodate a disability, as covered under the Equality Act 2010, will be determined on an individual basis, with advice and support from Occupational Health and Human Resources. Also, with advice from the Infection Control Nurse where appropriate. The policy describes standards for all employees and specific standards for those directly involved in the delivery of care. As well as the general standards, there are additional, more stringent requirements for staff providing direct care, who may or may not be required to wear uniform. In order to comply with this policy, all direct care employees must have enough sets of uniform (i.e. sufficient for daily changes) to facilitate good practice in the areas of infection control and health and safety. It is every employee s responsibility that this policy is upheld. The Trust has the right to expect that the standards in this policy are adhered to, and line managers will regularly monitor compliance. The aim of this policy is to ensure that all Trust employees are clear on the expected standard of their clothes while at work, whether uniform or non-uniform. The dress code details the standards and professional image which the Trust wishes to convey to all patients/clients, partners and members of the public. In all cases, the following principles should be supported and promoted, in order to adhere to the recognised legal framework: health, safety and wellbeing of patients; health, safety and wellbeing of employees; infection prevention and control; public confidence and professional image; professional accountability, as defined by professional bodies/councils. The objectives of this policy are: to ensure staff maintain a positive professional image; to ensure staff wear clothing in line with the principles of this policy; to ensure that infection control and health and safety issues are addressed; to ensure that service users are confident with the policy. 2. Scope This policy applies to all Trust employees. 3. Definitions Patient this term is used when referring to the NHS population as a whole. Also for the purpose of this policy it is used to mean service user, resident, client, etc. Direct care this term refers to employees in both clinical and non-clinical settings who give hands-on patient care, e.g. assisting with personal hygiene, giving injections. Non-direct care this term refers to staff who do not provide direct patient care. Permanent staff all employees who have a permanent contract with the Trust, both health and social care staff and bank workers. This includes staff employed by the Trust and 3 P a g e

4 working in other organisations. Temporary staff all employees, including those from Sheffield City Council who are seconded to the Trust, all bank and agency staff together with any contractors working for the Trust, and students/trainees on placements within the Trust. Volunteers any individual working as a volunteer on placement with the Trust. Infection, prevention and control is the prevention and management of infection through the application of research based knowledge to practices that include universal precautions, decontamination, waste management, surveillance and audit. PPE personal protective equipment. 4. Purpose The purpose of this policy is to ensure a consistent approach in wearing Trust uniform, and to portray a corporate image. The policy makes it explicit for all employee groups that the expectations of the Trust, in relation to the dress code, should present a professional appearance. 5. Duties 5.1 The Chief Executive has overall responsibility for all policies and procedures within the Trust. 5.2 Directors and Assistant Directors will ensure that this Policy is implemented within their area(s) of responsibility. 5.3 Human Resources Department and the Workforce Development Team will provide appropriate advice and support throughout. A copy of this Policy will be sent to all new employees with the Induction Pack and they will be advised with whom they may raise any concerns. 5.4 Managers and senior clinicians are responsible for ensuring the Policy is adhered to within their area(s) of responsibility and control. All staff will be made aware of this Policy as part of their induction process and existing employees made aware of any changes to this Policy via the Trust intranet/line manager. Managers must ensure that: all employees including temporary staff are aware of the standard of dress within the Policy; an initial set of uniform is ordered, dependant upon the role and hours worked; replacement uniforms are provided as required and in agreement with the line manager; policies are implemented, monitored and enforced; advice is sought from HR if unsure how/if compliance with this Policy is being met. 5.5 It is the responsibility of all employees to adhere to the standards of the dress code and professional appearance, as appropriate for their employee group and job role at all times. It is the employee s responsibility to: inform their manager in a timely manner should their uniforms need replacing; inform their manager if there s a discretionary reason they may need adjustments to be accommodated by this Policy; comply with this and any other associated policy and procedures; check with their line manager if unsure how this Policy may apply/not apply. 4 P a g e

5 5.6 The Infection Control Nurse will provide advice to all employees in relation to the risk of infection. The uniform/dress code will become part of the infection control audit programme, if appropriate. 5.7 Occupational Health will give advice if there are issues of compliance in relation to disabilities covered under the Equality Act Process Failure to follow this Policy may result in action under the Disciplinary Policy. 6.1 Personal Hygiene All employees should maintain a high level of personal hygiene and professional appearance. The chewing of gum is prohibited in all areas. However, nicotine gum can be used for the purposes of smoking cessation but must refrain when dealing directly with patients, carers or the general public (including telephone calls). 6.2 Make up and Finger Nails make up should be discreet and minimal. If working in non-clinical areas, nails should be clean and nail varnish, where it is worn, should be in good condition; if working in clinical practice/patient and client care or within housekeeping and food handling, false/acrylic nails and nail varnish are strictly forbidden as they pose an infection control risk; 6.3 Jewellery - general Employees should ensure that their jewellery is minimal so that it does not pose a risk to themselves or others and promotes a professional image. Facial piercing should remain discreet and facial jewellery should be plain and flat. This is to avoid potential harm as well as presenting a professional appearance. Staff whose religion or belief requires them to wear a religious symbol may do so provided they are discreet and comply with infection control and health and safety procedures. 6.4 Health and Safety Employees must fully cooperate in meeting their legal responsibilities in relation to the Health & Safety at Work etc Act Clothing and footwear should be appropriate for the type of work individuals carry out, and not expose themselves or others to unnecessary risk. Potential hazards relating to clothing worn should be considered as part of the risk assessment process. Employees issued with PPE or clothing for their safety must ensure they are worn, stored, used, cleaned, maintained, serviced and disinfected, as appropriate, and in accordance with the manufacturer s recommendations (the PPE at Work Regulations 1992 refers.) 6.5 Identification Badges employees must wear their Trust photographic identification badges at all times in all areas of the organisation for security and identification purposes. Whilst not on duty, when away from Trust premises, eg taking a lunch break or at the end of the day, the ID badge should be covered or removed for personal safety reasons; non-direct care staff can wear safety lanyards, whilst direct care staff will have a clipon badge for infection control and practical reasons; employees who are out in the community with patients should ensure that they have their ID badge on them in the event they are required to formally identify themselves. 6.6 Changes to Dress Code Policy There may be circumstances where the adherence of all or part of the dress code may cause 5 P a g e

6 difficulties/discomfort to employees. One example of this is in extremely hot or cold weather. Changes to the dress code may be allowed at local level and, following discussions with staff/hr, managers have discretion to agree such changes. However this must be professional and respect the general principles specified throughout this Policy. All employees are expected to use their discretion and judgement in deciding with their manager appropriate clothing for the task they are to carry out, for example playing football with patients. 6.7 Losses and Compensation If clothing or personal belongings are damaged in the course of an employee s duties, they are obliged to report this via their line manager and complete the Trust s incident/accident form. A claim may then be made via the Losses and Compensations Procedure and if, following consideration of the circumstances, this is agreed by the Directorate Management Team then reasonable reimbursement will be made by the Trust. In the case of spectacles, compensation for damage in most cases would be for the full value, except where the cost of the frames is deemed excessive or where the employee is making a claim via their own insurance. It is important, therefore, for staff to give consideration to the cost of what they wear for duty. All employees are expected to use their discretion and judgement in deciding with their manager the appropriate clothing for the task(s) they undertaking. 6.8 Non-uniformed staff Employees who wear their own clothes should ensure that they are suitable for work purposes, clean and in a good state of repair, as well as looking professional at all times. The following should be avoided: clothes that are revealing and may cause embarrassment or offence, (i.e. above mid thigh length; showing the midriff or underwear); clothes with logos or advertisements and sports clothing, etc; clothing that could be interpreted as intimidating or threatening, (i.e. combat fatigues); ripped or torn clothing; denim jeans are not normally seen as acceptable wear for staff working on inpatient and residential settings as denim jeans may not be seen as professional wear. However, managers may still use their discretion. To ensure effective communication, clothing which covers the face is generally not permitted for employees in contact with patients, carers or visitors, nor for staff in other roles where clear face to face communication is essential e.g. training. Staff in these areas who wish to wear a veil for religious reasons when they are not working, e.g. during lunch breaks, may do so. 6.9 Non-uniformed staff in direct patient contact Employees who wear their own clothes rather than a uniform (e.g. community staff, resource centre staff and medics) when working in a care/clinical environment should adhere to the general principles of the standards set out above. In particular, they should ensure that their clothes, shoes and jewellery do not pose a potential hazard to themselves, patients/clients and other employees from both an infection control and a health and safety perspective Uniformed staff All housekeeping, catering, portering, driving, nursing, therapy and out of hours staff who are uniformed are required to wear the uniform provided and agreed by the Trust, including PPE. 6 P a g e

7 For employees who wear a uniform when working, the following must be observed: Those who are required to wear a uniform will be provided with an adequate number of uniforms by the Trust. The Trust will, within resources available, purchase quality clothing that meets infection control and health and safety requirements, and reduces replacement costs. The uniform provided must be worn and maintained in a clean condition and in good repair. Employees must presume some degree of contamination, even on uniform or clothing which is not visibly soiled. They must, therefore, change out of their uniform promptly at the end of each shift. A clean and freshly laundered uniform must be worn daily. All uniforms must be clean, ironed and presentable on commencement of shift. Employees should have access to a spare uniform in case of accidental contamination by blood, body fluids or other noxious/toxic substances Direct care/housekeeping staff/similar roles Additional requirements: -clothing should allow sufficient hip and shoulder movement for the safe moving and handling requirements of the job; -clothing should be smart, safe and practical and should provide the wearer with mobility and comfort. Tights, socks, etc (eg blue, black or neutral colour) should not detract from the overall presentation of the uniform; -clothing should be durable enough to withstand water temperatures of at least 65 centigrade to minimise the risks of cross infection; -clothes should be purchased with the client group in mind, reflecting the type of work undertaken. Employees should not wear neck ties during any care activity which involves patient contact. Washable cardigans may be worn but not when in care/clinical areas and/or attending to patients. These are not provided by the Trust, but if required, can be provided by the individual. -where a headscarf or veil is worn, as part of religious or belief observance, staff must ensure that the flow of the garment does not interfere with work practice. These must be changed on a daily basis to minimise cross infection and the risk of personal injury. Any employee who has a need for special clothing consideration, e.g. due to having a disability under the Equality Act, should bring this to the attention of their line manager. Support and guidance can be obtained from Occupational Health and the Infection Control Nurse, as necessary. Pens/scissors or any other sharp instrument should not be carried outside of breast pockets as this may cause injury when moving patients. Such items should be carried in hip pockets or inside breast pockets, and should be removed whilst carrying out patients duties. All direct staff, when they are on duty, should wear their regulation uniform, in compliance with this Policy. This will also project a professional image and encourage public trust and confidence, as well as contribute to the corporate Trust image. Employees should change into non-uniform clothing before leaving work Infection Control Good hand hygiene is well recognised as the single most important factor in the prevention of cross infection (see the Trust s Infection Prevention and Control Policy). However, contact transfer of bacteria from uniforms leading to infection has also been recognised. Studies show that uniforms are frequently contaminated by disease, causing bacteria, 7 P a g e

8 including Staphylococcus Aureus and Clostridium Difficile. For this reason staff must apply the Bare Below Elbow principles (i.e. all wrist and hand jewellery must be removed, except one plain ring with no stones. No long sleeves below the elbow are allowed). When undertaking care/clinical procedures, including preparation like hand washing, long sleeve garments (e.g. cardigans) must be removed to prevent contamination. Where long sleeve garments cannot be removed (e.g. blouses or shirts) it must be possible for the sleeves to be rolled up to above elbow height, and for them to remain up independently throughout the duration of the procedure. All employees working in care/clinical areas and giving direct care must adhere to the Bare Below Elbow principles. Maximum contamination occurs in areas of greatest hand contact, eg pockets, cuffs and apron areas, allowing the recontamination of washed hands. Higher numbers of organisms have been found on the hands of staff wearing rings and the presence of rings has also shown to decrease the effectiveness of hand washing. (See the Infection Prevention and Control Policy). It is important to note that the hand washing solution must come into contact with all surfaces of the hands. Employees need to ensure they use appropriate protective clothing, as required, to protect their uniforms and reduce the risk of them becoming contaminated. Plastic aprons must be removed before leaving the ward, a patient s home or any clinical areas and changed between patients in order to adhere to infection control principles Hair Hair should be clean, and off the collar, to reduce the incidence of bacterial growth around the collar. Care/clinical employees should have their hair tied back (male and female) if longer than shoulder length. This applies to all hairstyles and types, including extensions, wigs, etc. Where hair clips are worn, they must not have the potential to injure staff or patients, and must comply with health and safety and infection control standards Jewellery for clinical roles The Bare Below Elbow principles apply to jewellery. Care/clinical employees may wear a plain ring with no stones and one small pair of plain stud earrings. Fob watches should not be worn on the outside of clothing. Wrist watches must be removed when giving direct patient care. No necklaces, bracelets or anklets are to be worn. Facial piercings should remain discreet and facial jewellery should be plain and flat. Any piercings or jewellery which may cause an infection control hazard must therefore be covered or removed. Employees who are required to wear jewellery for religious reasons e.g. a Kara (steel bangle) may do so provided that it is pushed up the arm and taped to enable effective hand hygiene. No badge should be worn on clothing, except for ID and another badge e.g. cleanyourhands Tattoos Employees who have tattoos should ensure that they are not visible wherever possible Footwear Shoes must be suitable for the work task. They should be leather/leather type with a rubber non-slip sole and low heel; give adequate support and be strong enough to prevent damage to toes should anything be dropped on the feet. They should be lace up or slip-on full shoe. These are provided by the individual. Backless and/or open toe shoes or sandals and mules must not be worn as these constitute a hazard (refer to Manual Handling Operations Regulations 1992). If alternative footwear is required for medical purposes, the individual will be required to provide medical evidence. 8 P a g e

9 6.17 Mobile Phones and Bleeps Employees engaged in clinical activity within a community setting should keep their mobile phone and/or bleep on silent or vibrate whilst giving direct patient care, and only deal with a call between clinics/patients visits. Exceptions are medics and staff on call or stand-by. (See Mobile Communication Devices Policy) No Smoking All employees must adhere to the Trust s Nicotine Management and Smoke Free Policy (available on the intranet), that is, no smoking in or near any Trust site Temporary Employees, including students Any bank or agency staff undertaking work on Trust premises should comply with the principles of this Dress Code Policy. Students have their own university uniform, but they are nevertheless expected to adhere to this Policy whilst working on placement within the Trust. They should demonstrate a professional appearance Maternity Clothing Suitable work clothing will be provided for pregnant clinical staff who are expected to wear uniform, as required. 7. Dissemination, storage and archiving An all staff will be sent out to alert employees to this revised Policy, within one week of ratification. The Policy will also be available on the Trust Intranet. Previous versions of this Policy will be archived by HR. 8. Training and other resource implications ETD should ensure all staff with significant Infection Prevention and Control risks attend training days appropriate to each staff group (see Risk Management website and Infection Prevention and Control Policy). On induction, both corporate and local, all employees will receive infection prevention and control training/education. New starters will also be provided with a copy of the Dress Code Policy. Details of Infection Prevention and Control training expected and provided by the Trust can be found in the Infection Prevention and Control Policy. Also reference should be made to the Risk Management Training matrix and process. Training sessions will also make general reference to clothing, uniforms, use of personal protective equipment, etc. Extra resources - managers need to review with teams if any other resources are needed in order to comply with this Policy. 9. Audit, monitoring and review The policy will be reviewed after 3 years, or earlier should any changes occur. 9 P a g e

10 Monitoring Compliance Template Minimum Requirement Policy content, including duties and process. Process for Monitoring Review of policy. Responsible Individual/ group/ committee HR Directorate Partner Frequency of Monitoring 3 yearly, or before to meet regulatory or statutory requirements. Review of Results process (e.g. who does this?) Joint Consultative Forum / HR Policy Group Responsible Individual/group/ committee for action plan development HR Directorate Partner Responsible Individual/group/ committee for action plan monitoring and implementation Joint Consultative Forum / HR Policy Group 10. Implementation plan Action / Task Responsible Person Deadline Progress update New policy to be uploaded onto the Intranet and Trust website. Director of Corporate Governance Within 5 working days of ratification A communication will be issued to all staff via the Communication Digest immediately following publication. A communication will be sent to Education, Training and Development to review training provision. A copy of the policy to be included in the Induction Pack. Director of Corporate Governance Director of Corporate Governance Head of Education, Training and Development Within 5 working days of ratification Within 5 working days of ratification Next scheduled induction following issue. 11. Links to other policies, standards and legislation (associated documents) This policy should be read in conjunction with the following specific policies; Infection Prevention and Control Mobile Communication Devices Nicotine Management and Smoke Free Policy Health and Safety Policy Statement Security Policy 12. Contact details Title Name Phone HR Business Partner Jane Askew Infection Control Nurse Jeanette Lee References The main legislation that affects an organisation response to the transmission of infections via uniforms or work wear is outlined below: 10 P a g e

11 The Health and Safety at Work, etc, Act 1974 sections 2 and 3. Section 2 covers risks to employees and section 3 to others affected by their work, eg patients. The Control of Substances Hazardous to Health Regulations 2002 (as amended) (COSHH). Further information about COSHH and its applicability to infection control can be found at The Management of Health and Safety at Work Regulations 1999 (Management Regulations), that extend the cover to patients and others affected by microbiological infections, and include control of infection measures. Securing Health Together, the Health and Safety Executive (HSE) long term strategy for occupational health, that commits HSE/Health and Safety Commission and their fellow signatories (including the Department of Health) to a 20 per cent reduction in ill health caused by work activity by Health Act 2006, Code of Practice revised Jan Duty 4, to maintain a clean and appropriate environment includes at section (g) that the supply and provision on linen and laundry reflects Health Service Guidance HSG95 (18), as revised from time to time and at section (h) that clothing (including uniforms) worn by staff when carrying out their duties is clean and fit for purpose. 11 P a g e

12 Appendix A Version Control and Amendment Log Version No. Type of Change Date Description of change(s) 3.0 Review / ratification / issue October 2016 Policy revised and updated for new policy template. 12 P a g e

13 Appendix B Dissemination Record Version Date on website (intranet and internet) Date of all SHSC staff Any other promotion/ dissemination (include dates) 3.0 October 2016 October 2016 N/A minimal changes. 13 P a g e

14 Equality Impact Assessment Process for Policies Developed Under the Policy on Policies Stage 1 Complete draft Policy Appendix C Stage One Equality Impact Assessment Form Stage 2 Relevance - Is the Policy potentially relevant to equality i.e. will this Policy potentially impact on staff, patients or the public? If NO No further action required please sign and date the following statement. If YES proceed to stage 3 This Policy does not impact on staff, patients or the public (insert name and date) Stage 3 Policy Screening - Public authorities are legally required to have due regard to eliminating discrimination, advancing equal opportunity and fostering good relations, in relation to people who share certain protected characteristics and those that do not. The following table should be used to consider this and inform changes to the policy (indicate yes/no/ don t know and note reasons). Please see the SHSC Guidance on equality impact assessment for examples and detailed advice. This is available by logging-on to the Intranet first and then following this link AGE DISABILITY GENDER REASSIGNMENT PREGNANCY AND MATERNITY RACE RELIGION OR BELIEF SEX SEXUAL ORIENTATION Does any aspect of this Policy actually or potentially discriminate against this group? Can equality of opportunity for this group be improved through this Policy or changes to this Policy? No No No No Equality Act defines disability which includes sensory impairment, visible or non-visible disabilities No No No No No No No No No No No No No No No No No No No Can this Policy be amended so that it works to enhance relations between people in this group and people not in this group? Stage 4 Policy Revision - Make amendments or identify any remedial action required (action should be noted in the policy implementation plan section) Please delete as appropriate: Policy Amended / Action Identified / no changes made. Impact Assessment Completed by (insert name and date) Jean Stockdale, 10 October P a g e

15 Appendix D - Human Rights Act Assessment Form and Flowchart You need to be confident that no aspect of this policy breaches a person s Human Rights. You can assume that if a policy is directly based on a law or national policy it will not therefore breach Human Rights. If the policy or any procedures in the policy, are based on a local decision which impact on individuals, then you will need to make sure their human rights are not breached. To do this, you will need to refer to the more detailed guidance that is available on the SHSC web site (relevant sections numbers are referenced in grey boxes on diagram) and work through the flow chart on the next page. 1. Is your Policy based on and in line with the current law (including case law) or Policy? X Yes. No further action needed. No. Work through the flow diagram over the page and then answer questions 2 and 3 below. 2. On completion of flow diagram is further action needed? N/A as no flow diagram in this Policy. No, no further action needed. Yes, go to question 3 3. Complete the table below to provide details of the actions required Action required By what date Responsible Person 15 P a g e

16 Human Rights Assessment Flow Chart Complete text answers in boxes and highlight your path through the flowchart by filling the YES/NO boxes red (do this by clicking on the YES/NO text boxes and then from the Format menu on the toolbar, choose Format Text Box and choose red from the Fill colour option). Once the flowchart is completed, return to the previous page to complete the Human Rights Act Assessment Form. 1.1 Dress Code Policy To ensure a consistent approach to dress and uniform All employees.. 1 Will the policy/decision engage anyone s Convention rights? YES Will the policy/decision result in the restriction of a right? YES NO NO Flowchart exit There is no need to continue with this checklist. However, o Be alert to any possibility that your policy may discriminate against anyone in the exercise of a Convention right o o Legal advice may still be necessary if in any doubt, contact your lawyer Things may change, and you may need to reassess the situation Is the right an absolute right? 3.1 YES NO 4 The right is a qualified right Is the right a limited right? YES Will the right be limited only to the extent set out in the relevant Article of the Convention? NO YES 1) Is there a legal basis for the restriction? AND 2) Does the restriction have a legitimate aim? AND 3) Is the restriction necessary in a democratic society? AND 4) Are you sure you are not using a sledgehammer to crack a nut? YES NO Policy/decision is likely to be human rights compliant BUT Policy/decision is not likely to be human rights compliant please contact the Head of Patient Experience, Inclusion and Diversity. Get legal advice Regardless of the answers to these questions, once human rights are being interfered with in a restrictive manner you should obtain legal advice. You should always seek legal advice if your policy is likely to discriminate against anyone in the exercise of a convention right. Access to legal advice MUST be authorised by the relevant Executive Director or Associate Director for policies (this will usually be the Chief Nurse). For further advice on access to legal advice, please contact the Complaints and Litigation Lead. 16 P a g e

17 Appendix E Development, Consultation and Verification o Human Resources Dept was involved in developing the Policy and any guidance followed. o Groups and individuals consulted (included staff side groups). o Updated changes only made to the Policy. o Verified at JCF on 21 September P a g e

18 Appendix F Policies Checklist Please use this as a checklist for policy completion. The style and format of policies should follow the Policy Document Template which can be downloaded on the intranet. 1. Cover sheet All policies must have a cover sheet which includes: The Trust name and logo The title of the policy (in large font size as detailed in the template) Executive or Associate Director lead for the policy The policy author and lead The implementation lead (to receive feedback on the implementation) Date of initial draft policy Date of consultation Date of verification Date of ratification Date of issue Ratifying body Date for review Target audience Document type Document status Keywords 2. Contents page Policy version and advice on availability and storage 3. Flowchart N/A 4. Introduction 5. Scope 6. Definitions 7. Purpose 8. Duties 9. Process 10. Dissemination, storage and archiving (control) 11. Training and other resource implications 12. Audit, monitoring and review This section should describe how the implementation and impact of the policy will be monitored and audited and when it will be reviewed. It should include timescales and frequency of audits. It must include the monitoring template as shown in the policy template (example below). 18 P a g e

19 Monitoring Compliance Template Minimum Requirement Process for Monitoring Responsible Individual/ group/ committee A) Describe which aspect this is monitoring? e.g. Review, audit e.g. Education & Training Steering Group Frequency of Monitoring e.g. Annual Review of Results process (e.g. who does this?) e.g. Quality Assurance Committee Responsible Individual/group/ committee for action plan development e.g. Education & Training Steering Group Responsible Individual/group/ committee for action plan monitoring and implementation e.g. Quality Assurance Committee 13. Implementation plan 14. Links to other policies (associated documents) 15. Contact details 16. References 17. Version control and amendment log (Appendix A) 18. Dissemination Record (Appendix B) 19. Equality Impact Assessment Form (Appendix C) 20. Human Rights Act Assessment Checklist (Appendix D) 21. Policy development and consultation process (Appendix E) 22. Policy Checklist (Appendix F) 19 P a g e

20 Most localities in the Trust do not have the facilities for uniform laundering. Staff are required to wash their own uniform. The following guidance should be followed when handling and decontaminating socially soiled uniforms: Appendix G Laundry Guidelines a) Wash separately from other items, in a washing machine at (65-71 centigrade if possible) a high temperature. b) Wash in laundry detergent in the quantities recommended by the manufacturer (type, for example, biological etc, is not important). c) Dry quickly, or tumble dry and iron. d) Hand washing uniform is ineffective and therefore not acceptable (RCN, 2005). As most localities in the Trust do not provide changing facilities, the uniform must be covered discreetly for the journey to and from the workplace, or between patients. Uniform must not be worn in any retail or recreational premises whilst not at work. This not only poses an infection control risk, but also members of the public have expressed concerns regarding employees wearing uniforms in public places due to the perceived risk from infection. Laundered uniforms must be stored in a plastic bag to prevent contamination, and carried separately from other items. Clean and dirty uniforms should not be transported together. Employees who have been working in a contaminated area should change as soon as possible placing the clothing in a plastic bag, and then seek specific advice from the Infection Control Team on how to decontaminate their clothing. See Infection Prevention and Control Policy. 20 P a g e

21 Appendix H Expected standards and reasons Employees should wear their own clothes when travelling to and from work places. If not, uniforms must be fully covered. Aprons must be worn where contamination may occur. They must be disposable, for single use. Aprons must be changed when moving between patients at all times. This minimises the risk of cross infection (both in reality and in the publics perception). It also protects staff from contamination and minimises cross infection. Uniforms must be clean and changed daily if staff are providing direct patient care to reduce the risk of cross infection. Employees are required to use designated changing facilities where available and are discouraged from using staff or public toilet areas as changing areas. This minimises cross infection cardigans / sweatshirts: where these are worn for warmth, they should suit the colour of the uniform and have no logos (or NHS permissible logos), be plain in colour, and must be in a good state of repair. This article of clothing must be removed when carrying out any clinical or direct care procedure. Employees must ensure professional appearance is maintained and to minimise cross infection. Jewellery: staff involved in direct patient care should keep jewellery to a minimum. Wristwatches and bracelets also restrict effective hand washing and must not be worn in clinical areas by employees involved in direct patient contact. Jewellery is, therefore, restricted to one plain wedding band and one pair of plain stud earrings. Rings should not be worn on chains around the neck. NB: If there is a cultural reason for the wearing of jewellery this should be raised with the line manager and agreed at their discretion. Piercing: any visible body piercing (except plain studs earrings) should be removed whilst at work or if unable to do so, should be kept to a minimum, be discreet and inoffensive. Hand hygiene cannot be compromised by hand and wrist jewellery. A new piercing will colonise high levels of micro-organisms and it may be appropriate to cover with a plaster. Footwear: for employees providing clinical care, shoes should be soft soled, non-pervious, non-slip and plain and must have enclosed toes and heels. This upholds appearance of uniform wearer and helps prevent injury. Fingernails: keep finger nails short and clean. No nail varnish or false nails or extensions should be worn in clinical areas by employees involved in direct care. False nails harbour micro-organisms and can reduce compliance with hand hygiene. Also long nails may cause injury to patients. Note: it has been shown that nails, including chipped nail polish, can harbour potentially harmful bacteria, which could then be transmitted to those who are receiving care. Head scarves: where a headscarf or veil is worn, as part of religious observance, employees must ensure that the flow of the garment does not interfere with the work practice. The scarf or veil must be changed daily. This minimises cross infection and the risk of personal injury. 21 P a g e