The Newcastle upon Tyne Hospitals NHS Foundation Trust Visitors Policy Version No. 1.1 Effective From 18 th October 2012 Expiry Date 30 th September 2015 Date Ratified 14 th September 2012 Ratified By Matrons Forum 1. Introduction The Newcastle upon Tyne Hospitals NHS Foundation Trust cares for many vulnerable patients and must provide an appropriate environment for the delivery of high quality care. The Trust is continuously striving to minimise and reduce the risk of Health Care Acquired Infections (HCAI) and highlights the responsibility of the patients visitors. However, the Trust also recognises the importance of ensuring the psychological wellbeing of patients by providing visitor access to relatives, carers and friends. 2. Policy Scope This policy applies to all patients, relatives, carers and their families. The policy details arrangements to support specific patient needs in a safe, clean and comforting environment. Visitors are asked to respect the following: Visiting times Infection Prevention and Control guidance Equality and diversity Privacy and dignity. 3. Aim of the policy This policy is supported by a visitor information leaflet, which is available in all clinical areas throughout the Trust. It is the responsibility of the Sister/Charge Nurse to ensure that the leaflet is visible and available to all patients, relatives, carers and friends. 4. Roles and Responsibilities 4.1 Trust Board The Director of Nursing and Patient Services is accountable to the Trust Board for ensuring Trustwide compliance with the policy. Page 1 of 5
4.2 Director of Nursing and Patient Services The Heads of Nursing are accountable to the Director of Nursing and Patient Services for ensuring policy implementation in relation to their respective areas of responsibility. 4.3 Head of Nursing The Matrons are accountable to the respective Head of Nursing for ensuring policy implementation in their Directorate. 4.4 Matron Ward managers are responsible to the Matron for ensuring policy implementation on their respective ward(s). 4.3 Ward Managers Ward managers are responsible for ensuring policy implementation and compliance in their area(s) 4.4 All staff All staff are responsible for complying with the policy. 5. Visiting Times 5.1 Visiting access is restricted to allow patients time to receive treatment /care, recover, rest and eat meals without interruption. Clinical interventions should be minimised as far as possible during visiting times. Visiting times must be displayed at ward entrances. In most areas these are: 2pm - 4pm 6pm - 8pm The Sister / Charge Nurse is the gatekeeper in the application of this policy and may make allowance in exceptional circumstances to allow visiting outside these times. Circumstances when this may occur include: When a patient is receiving palliative care and specific support and care is required. In specific circumstances to support a patient, e.g. a vulnerable patient. Provide support with nutrition and meeting personal hygiene needs, as a reasonable adjustment for patient with a Learning Disability or other special need Page 2 of 5
Paediatric patients. /Transitional Young Adults Maternity patients - All maternity wards allow 3 visitors to a bed or cot - Open visiting for Dads throughout maternity and parents on NICU - No children under the age of 16 are permitted in NICU unless they are siblings Critical Care patient:-. - Visitors permitted based on personal circumstances - Visiting times should reflect the needs of the general patient group of each speciality. Over stimulation and fatigue should be avoided. Some areas have designated rest periods which must be respected. It is the responsibility of the ward Sister/Charge Nurse via ward staff to communicate these times to visitors. 5.2 Infection Prevention and Control Guidance In order to minimise the risk of HCAI, staff must ensure that: A maximum of 2 people visit at any one time, unless special permission is granted by the ward sister/charge nurse. Visitors must not visit if they have an infection e.g. cough, cold, unexplained rash, diarrhoea and/or vomiting. They must be symptom free for 48 hours prior to returning to the ward and must seek advice from the ward Sister/Charge Nurse if unsure. Visitors must clean their hands when entering or leaving an adult ward/unit. Alcohol gel or liquid soap and water can be used. Visitors should also be advised to wash hands on leaving an isolation area. Visitors to any children s ward/unit must wash their hands with soap and water on entry to and on leaving the ward/unit the ward. (Alcohol hand gel is not available because of the risk it poses to children if misused). Visitors must not sit / lie on the bed. Visitors should be discouraged from bringing high risk foods in to hospital; specific dietary requirements should be discussed with the ward Sister/Charge Nurse. Visitors must not use the patients toilets. Toiletries, tissues, towels etc. must not be shared with other patients. Visitors are prohibited from touching wounds or medical devices. Visitation of young children is limited to circumstances relating to improved patient care, e.g. in the interests of the patient or the child. The Sister/Charge Nurse should agree all requests. Children must be supervised at all times. Occasionally visiting may be further restricted due to an outbreak of infection. In the event of an Outbreak, the ward Sister/Charge Nurse must Page 3 of 5
ensure that this is clearly conveyed by appropriate signage at the entrance of the ward and appropriate Infection Prevention and Control processes are in place for all visitors to follow. 5.3 Privacy and Dignity 5.4 Pets The provision of privacy and dignity for patients is an essential aspect of care and a very high priority for the Trust. Visitors must be asked to respect patients privacy and dignity at all times. Visitors should be asked to leave the room/bay when necessary. In very exceptional circumstances pets may be allowed into the clinical area at the discretion of the ward Sister/Charge Nurse. Please refer to the Animals in Hospital Policy. 6. Application The following additional policies support guidance detailed in the Visitors Information Leaflet: Animals in Hospital Car Parking Hand Hygiene Medical devices Mobile Phones Patients Property Smoke Free Ward food Hygiene The Trust has a zero tolerance policy for abuse of any staff, patients or relatives. Contravention of the Trust Policy Management of Violence and Aggression at Work may lead to sanctions ranging from limitation of visiting rights to an outright ban. In extreme circumstances Trust security staff or the Police may be called. Further advice on the implementation of this policy can be obtained from Matrons or the Heads of Nursing. 7. Equality and Diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed. Page 4 of 5
8. Monitoring Standard/ process / Issue Patients views Complaints Monitoring and audit Method By Committee Frequency Patient Matrons Matrons Annually satisfaction Forum surveys will address visiting. Review of complaints received, if any, to establish if there are any trends / themes. Matrons Matrons Forum Annually 9. Consultation and review A group of Matrons initially reviewed the policy to establish whether any changes were required from the previous version of the policy. Only minor changes were identified as being required and these were discussed at the Matrons Forum. Author: Director of Nursing and Patient Services. Page 5 of 5
THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST IMPACT ASSESSMENT SCREENING FORM A This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Policy Title: Visitors Policy Policy Author: Director of Nursing and Patient Services Yes/No? You must provide evidence to support your response: 1. Does the policy/guidance affect one group less or more favourably than another on the basis of the following: (* denotes protected characteristics under the Equality Act 2010) Race * No Ethnic origins (including gypsies and travellers) No Nationality No Gender * No Culture No Religion or belief * No Sexual orientation including lesbian, gay and bisexual people * No Age * No Disability learning difficulties, physical disability, sensory impairment and mental health problems * No Gender reassignment * No Marriage and civil partnership * No 2. Is there any evidence that some groups are affected differently? No 3. If you have identified potential discrimination which can include associative discrimination i.e. direct discrimination against someone because they associate with another person who possesses a protected characteristic, are any exceptions valid, legal and/or justifiable? N/A 4(a). Is the impact of the policy/guidance likely to be negative? (If yes, please answer sections 4(b) to 4(d)). N/A 4(b). If so can the impact be avoided? N/A 4(c). What alternatives are there to achieving the policy/guidance without the impact? N/A 4(d) Can we reduce the impact by taking different action? N/A Comments: Action Plan due (or Not Applicable): N/A Name and Designation of Person responsible for completion of this form: Sue Cook, Matron Date: 14/09/2012 Names & Designations of those involved in the impact assessment screening process: Matrons Forum (If any reader of this procedural document identifies a potential discriminatory impact that has not been identified on this form, please refer to the Policy Author identified above, together with any suggestions for the actions required to avoid/reduce this impact.) For advice on answering the above questions please contact Frances Blackburn, Head of Nursing, Freeman/Walkergate, or, Christine Holland, Senior HR Manager. On completion this form must be forwarded electronically to Steven Stoker, Clinical Effectiveness Manager, (Ext. 24963) steven.stoker@nuth.nhs.uk together with the procedural document. If you have identified a potential discriminatory impact of this procedural document, please ensure that you arrange for a full consultation, with relevant stakeholders, to complete a Full Impact Assessment (Form B) and to develop an Action Plan to avoid/reduce this impact; both Form B and the Action Plan should also be sent electronically to Steven Stoker within six weeks of the completion of this form. IMPACT ASSESSMENT FORM A October 2010