Posted By Messy Shaw
On the back of recent thread here re smoking in hostel bedrooms, what if the type of client means that they are particularly challenging and simply cannot comply with instructions?......


I have come across a large residential home for those suffering enduring & very challenging mental illnesses. Some also have learning disabilities. This building is designated as healthcare (not resi-care) so smoking is banned by law.

Controlling the risks posed by smoking has always been an issue here, but since the smoking ban was introduced, the situation has considerably worsened. In the main this is due to the non compliance of the residents who smoke openly throughout the building. The nature of their disabilities and (since the smoking ban) the lack of ashtrays) has resulted in thousands (yes thousands) of burn marks in flooring, curtains, furniture and bedding and two small bedroom fires..

The staff do try and manage as best as they can, but with no way of 'enforcing' the smoking ban there is little they can do other than guide the punter out of the building when found smoking and keep a log of these occasions. Indeed the staff are quite anxious as to their liabilities as they see a tragedy is only a matter of time, particularly at night when the staffing levels fall to the minimum (perhaps, less than minimum with regards to managing an evacuation). I have to say, I tend to agree with them.

The organisation who run the building have turned down advice (from previous FRAs) to increase staff training (by one additional session per year) and numbers of staff at night. They have also refused to employ more cleaning staff to empty waste bins more regularly (the origin of the last 2 fires there) and their representative simply laughed out loud when I mentioned sprinklers or water mist systems as they apparently have no cash.

This cannot be the only such building suffering these smoking problems. So have you encountered similar problems - a high risk environment - a high risk occupancy and a management with little cash? And if so, what were your actions/advice/recommendations?

Refusing treatment/care to these clients on the grounds of continued smoking within the building is out of the question

I have sent my FRA with numerous findings, and I know that my responsibilities are 'covered' from a legal point of view. But this one keeps on niggling me as these very vulnerable people have been let down (fire safety wise) by these ridiculous no smoking rules which have put them at much greater risk. I know the situation will be the same next year.

Posted By Ron Hunter
Just to be clear on the FRA: You may have prepared one, but ownership and responsibility surely rests elsewhere.
You can have a 'designated room' if this is a care home, or 'designated bedrooms' if it's a hostel.
It is IMHO incorrect to say the no-smoking policy isn't possible. Difficult and challenging, yes - but not impossible. That certainly wouldn't wash in Court.
p.s. If the Insurers for the premises get any inkling of goings-on, or perhaps sight of your FRA (a document they usually take an interest in) you may find the cover being withdrawn. And if you've no insurance..............

Posted By martinw
Hi Messy
at the top of your post you said that this situation was healthcare rather than resi-care therefore smoking was banned by law.
Is it purely NHS, or is it funded by NHS and outsourced? Or purely private healthcare?
Just interested.
Martin

Posted By martinw
Which is one of the reasons why I asked if this was NHS, in which patient choice is a strong determining factor - even if it was sometimes bad for health. There is the risk of attack on staff if you refuse to give the cigarettes also.
There has been a huge debate since smoke free legislation came in because of the link between those with mental health issues and the associated incidence of smokers within those groups. Most of the debate has sided with the long term health effects of stopping smoking, but there is the situation which Messy has to deal with where most if not all of the aid available to help those within a care scenario with mental health issues stop smoking require loads of extra staff support, counselling, even psychosocial therapy and/or medication which seems not to be a possibility within the place under discussion.

Posted By Messy Shaw
Thanks for your replies.

The building is NHS healthcare, and as such, smoking is banned by law within the building.

Managing smoking in mental health settings is a different ball game than elsewhere in society. Sanctions may be a tool in virtually all other premises, but with some extremely challenging clients it is less effective. Some may not understand and some will flatly refuse to be compliant. It is often not possible to simply ban the client because they insist on smoking (as you may wish to with other client groups, ie a customer in a Tesco store). It is also not possible to simply reinstate ashtrays as the staff would then be breaking the law

This building is 'open' which means that clients can leave the building and go shopping. Other buildings have a mix of clients, some of who can leave and some that cannot. In both types of buildings, clients have easy access to smoking materials.

In secure buildings, clients may need to be escorted to the external smoking point which creates a huge demand on staff resources. Some units have a smoking timetable, were Mr Smith is due for a smoke at 11:30 and 13:30 (and so on). I am aware of numerous examples where the client has waited for his turn only to be told there is insufficient staff to escort him, so his turn is 'cancelled' As a result, the client may become aggressive or violent putting extra strain on the staff. There is some limited access to extra support with regards to assisting clients to stop smoking,and other therapies, but many clients are far too poorly to be able to participate in such interventions. In any case, huge amounts of will power are required to stop smoking.People suffering from enduring mental illnesses are often just not strong or motivated enough to succeed.

There has been a recent survey of how the smoking ban has effected mental health units, but the findings of 'secret smoking' and the associated risk of fire have been (in my opinion) watered down. It states that whilst several small fires were reported via the survey, no serious fires have occurred. As a result, the reports recommendations in this area are pretty weak at best.

The report mentions the need for a uniform message from the NHS about the health risks from smoking and even if the ban was lifted, some PC led NHS Trusts would keep the ban as a public health message policy regardless of the risks of fire & staff assault and he trauma to the client.

So what to do? As stated in my earlier post, I have done all I can fro a FRA point of view. The staff on site do all they can. The Trust's management hide in their offices saying staff must just cope (very helpful!) and the law is clear - there is to be no smoking- full stop. The clients will not stop. The poor staff are in the middle, powerless to do anything.

Call me old fashioned, but if I killed a member of your family, or burnt your home down & served time in prison - I could smoke my lungs out 24/7 and HMP staff would be able to control the associated fire risk by providing ashtrays and smoking areas. However, if I (or you) was suffering a traumatic time in my personal life and went in to a mental health unit to recover, I would have to do without my fags, or smoke thereby breaking the law and creating risks of fire which staff are powerless to adequately control (putting them and my fellow patients at risk)

Something has gone badly wrong here.

Messy (non smoker)

The report referred to above is available here http://www.mentalhealth....eases-2009/22-june-2009/

Posted By water67.
Hi, can't really argue with what you say. In some areas the "ban" has not been thought through. We have a similar issue in day centres particularly for older service users or those recovering from mental health issues.. Many of whom can't go outside safely to smoke.. we don't have the resources to accompany them..e.g. member of staff..group of 8 or so at an activity..one wishes to go outside for a smoke..lets add it's middle of January freezing cold up here in north..as you can see add ons can make it difficult..we did, as a LA department make such points during the consultation period before the "ban" came into force..that day centres in such circumstances should be allowed a smoking room.."ignored"..thus we have this problem..if we take the ban smoking completely route..many people..some very vulnerable, just stop coming.. dilemma indeed..

ok we had our rant..lets get back to trying to control smoking.

cheers and good luck.

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