Document name:
Gym Policy
Document type:
Policy
What does this policy
replace?
New Policy
Staff group to whom it
applies:
All staff responsible for, and using,
Trust gyms
Distribution:
The whole of the Trust
How to access:
Intranet
Issue date:
October 2015
Next review:
October 2018
Approved by:
Executive Management Team
08.10.15
Developed by:
Trust Gym Steering Group. A
subgroup of the Medical Devices TAG
Director leads:
Director of Nursing, Clinical
Governance & Safety
Contact for advice:
Nicola Mirfin, Exercise Practitioner
Richard Watterston, Physiotherapy
Professional Lead
Gym policy
Draft 1.4
Gym Policy
1. Introduction
The Trust provides and supports the safe use of gyms in a variety of clinical areas.
This is in recognition of the value of exercise in assisting individuals to improve their
health & wellbeing.
2. Purpose
The purpose of this document is:



To describe the requirements when setting up a gym on trust premises.
To describe the requirements for operating a gym, ensuring patient
safety and compliance with medical devices guidance.
To describe the requirements for staff facilitating patients to use the
gym.
3. Definitions
3.1
A gym is any area in which there is a collection of exercise or fitness
equipment.
3.2
Exercise or fitness equipment is any equipment designed to increase the
heart rate by the use of physical exercise. It can consist of static exercise
equipment such as exercise bikes, rowing machines, cross trainers and
other such equipment and of resistance equipment that uses fixed weights
or free weights.
It excludes equipment used for the games such as footballs or badminton
and other nominal equipment such as mountain bikes and Nordic walking
sticks.
3.3
All exercise and fitness equipment meeting the criteria in 3.2 is classed as
a medical device.
The definition of a medical device in European and UK law is:
“any instrument, apparatus, appliance, material or other article, whether
used alone or in combination, including the software necessary for its
proper application intended by the manufacturer to be used for human
beings for the purpose of:
 diagnosis, prevention, monitoring, treatment or alleviation of disease;
 diagnosis, monitoring, treatment, alleviation of or compensation for an
injury or handicap;
 investigation, replacement or modification of the anatomy or of a
physiological process; and,
 control of conception,
and which does not achieve its principle intended action in or on the human
body by pharmacological, immunological or metabolic means, but may be
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assisted in its function by such means.” NHS England (2014)
NHS/PSA/D/2014/006
4. Duties for this policy
4.1
The Trust Board EMT is responsible for approving this policy.
4.2
The lead director is the Director of Nursing, Clinical Governance & Safety
4.3
The Trust Wide Clinical Policies and Procedures Group will be responsible
for ensuring that the policy has been developed in accordance with Trust
policy.
4.4
The directors of each BDU and their management teams will be
responsible for ensuring that any gym within their area of accountability is
maintained and operated in accordance with this policy.
4.5
All staff that support patients to use the gym, or use the gym themselves
need to be aware of and comply with the policy.
5. Setting up a gym
5.1
5.1.1
Approval
The decision to set up a gym must be made at BDU senior management
level. It must take into account the purpose of the gym, the suitability of the
facilities, the setup costs and the running costs.
5.1.2
Technical advice about the type and suitability of equipment must be
sought via the Physiotherapy Professional Lead and from the Infection
Control Lead Nurse. Equipment must be sturdy enough to cope with the
amount of use, the weight of the client and the environment in which it is
situated. Normally this will be medium to heavy use domestic quality
equipment, but some circumstances might require commercial standard
equipment. Light use domestic equipment is highly unlikely to be suitable.
5.1.3
Rooms used as gyms must be large enough for the equipment to be safely
located, with enough gaps between pieces of equipment to maintain safety
of people using the gym and with sufficient ventilation to maintain a
comfortable temperature, if in doubt contact the Estates department for
advice. Gym equipment must not be placed in areas where there is a flow
of pedestrian traffic, or where it can be accessed without supervision.
There should be the facilities within the gym to allow staff to summon help
without leaving the gym area. This may be in the form of a telephone or
through the ward alarm system.
5.1.4
Consideration must be given to the ability to release staff for training on
how to use the equipment and necessary updates. The ability to release
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staff to facilitate patient use of the equipment must also be considered as
should the opportunity for them to maintain competencies so that
unnecessary training places are not provided.
5.1.5
All equipment must be purchased through the Trust procurement
processes. Purchase of equipment will also include purchase of extended
warranty where this is advised and purchase of, or inclusion in a routine
maintenance contract, if appropriate to that piece of equipment.
5.1.6
All gym equipment will be asset-tagged and included on the trust asset
register.
5.2
5.2.1
Operation
A manager working in the service area must be identified as the
‘responsible manager’ for the gym.
5.2.2
A local operation procedure, incorporating the principles of this policy but
taking account of local situations, must be developed by the responsible
manager. This will include local booking arrangements and any specific
local safety requirements.
5.2.3
All gym equipment must be wiped down with an approved cleaning and
disinfection wipe between users. All equipment used must be wiped down
with an approved cleaning and disinfection wipe in-between users and at
the end of the gym session and a decontamination notice must be applied
to the equipment in such a position that it must be removed to enable the
equipment to be used again.
Specific advice on the cleaning and decontamination of the gym and its
equipment, including ordering details of suitable cleaning products, will be
sought from the Infection Prevention and Control Team.
5.2.4
All gyms will have a booking system that allows the use of the gym to be
booked in advance. Consideration must be given to numbers and to the mix
of patients when making bookings. In areas where staff have access to the
use of the gym it is not permissible for staff to be in the area at the same
time as patients, unless they are supporting patients. Under no
circumstances will staff use the equipment for their own purposes whilst
supporting patients.
5.2.5
All gyms will have a signing in system that allows the people using the gym
to be identified. This system should include the time that they entered the
gym, the time that they leave the gym and the staff member responsible for
supporting them.
Staff members using the gym are also required to use the signing in
system.
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5.2.6
All gyms will have a risk assessment for each piece of equipment. The risk
assessment will be carried out by a person with a relevant professional or
exercise qualification who is recognised by the steering group to undertake
this duty. This risk assessment will be available in the gym or the clinical
office of the responsible manager.
5.2.7
All gym equipment will have a safety checklist that must be followed.
5.2.8
Any equipment found to be faulty will immediately be taken out of use by
the staff member who discovered the fault or their manager. Equipment can
be authorised for use by the responsible manager once it has been
repaired. Use of faulty equipment will be recorded as an incident on the
Trust incident reporting system by the staff member who discovered the
fault..
5.2.9
Any equipment that has fallen outside of its maintenance schedule will
immediately be taken out of use by the responsible manager until it has
been maintained by a recognised person. Use of equipment that has fallen
outside of its maintenance schedule will be recorded as an incident on the
Trust incident reporting system.
5.2.10
Any equipment that breaks during use must be immediately quarantined by
the staff member supervising its use and not used until authorisation is
given by the Trust Health and Safety Team. The responsible manager for
the gym must be informed at the earliest opportunity. The Patient Safety
Team will decide whether the incident needs reporting through the national
patient safety systems, and make the report if required.
It is important that the equipment is not moved, repaired, or examined by a
representative of the manufacturer until the Health and Safety Team has
been informed.
Any incident of equipment failure whilst the equipment is in use should be
reported on the Trust incident reporting system by the staff member
supervising the use..
5.2.11
Any patient who is injured whilst using the equipment or who show signs of
ill health shall be seen by a first aider or a doctor as soon as possible. If the
injury is serious or the patient collapses an ambulance should be called
immediately.
It is important that staff supporting patients in the gym are aware of the
availability of nominated first aiders, the location of any resuscitation
equipment and have the means to summon these in an emergency without
leaving the patient.
All injuries should be recorded on the trust incident recording system.
5.2.12
A record of the patient’s activity should be made in the patients notes
following their use of the gym. It should include this individual’s
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psychological and physical response to the session, adherence or deviance
from the care plan and any notable events or recorded incidents during the
session.
5.3
5.3.1
Selection of Gym Users
All patients using the gym must have a physical health assessment prior to
first use defined by that service area. Any clinical conditions that may affect
their performance in the gym must be communicated to the staff supporting
them and to the staff member developing the gym program for them.
5.3.2
Patients who are not compliant with the agreed gym program or who do not
follow instructions in the gym will be reviewed for their suitability to attend
the gym.
5.3.3
When considering patients to use the gym a risk assessment should be
undertaken that identifies any physical health risk to the patient and any
behavioural risks that may put the patient, other patients or staff at risk.
5.4
5.4.1
Gym activities
All patients will exercise within the parameters of an individualised exercise
plan produced by an authorised member of staff, such as a physiotherapist,
a recognised exercise practitioner or an occupational therapist. This plan
will be reviewed and updated and they should be supported in undertaking
of the plan by the staff member accompanying them.
5.4.2
Only activities involving equipment in the gym should be undertaken in the
gym area.
5.5
5.5.1
Staff training
All staff supporting patients in the gym must undertake the trust gym
training and be assessed as being competent to supervise patients on the
equipment.
5.5.2
Staff must only support patients to use equipment on which staff have
been signed off as being competent to supervise.
5.5.3
Staff must supervise patients in the gym on a frequency that maintains
their competence to do so. They must also be able to assess the risks to
both the service user and the immediate environment.
5.5.4
A central register of staff trained to use the gym will be maintained. Staff
who have not maintained the competency will be removed from the
register.
5.5.5
The responsible manager for each gym must ensure that records of
training, use and maintenance for the gym are kept locally.
5.6
Staff use of gym equipment
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5.6.1
Staff may use gym equipment at the discretion of the responsible
manager for the location where the gym is situated.
5.6.2
Staff may only use the gym in their own time, when there are no patients
using the gym and when they are not preventing patients from using the
gym.
Staff may not use the gym whilst they are supervising patients.
5.6.3
Staff may only use equipment on which they have been assessed as
being competent and safe to use by an authorised person. This may have
been shown to them at locally arranged “drop in gym sessions” run by
designated staff members with expertise in the gym equipment and in the
gym they were trained.
5.6.4
Trust staff will not undertake health assessments or produce exercise
programmes for staff using the gym.
5.6.5
Staff are required to follow the rules relating to the gym in respect of
reporting damage and incidents.
5.6.6
Staff abusing the use of these facilities will have their access withdrawn.
6. Equality impact assessment
An equality impact assessment was completed. It found that no patients were
disadvantaged in the use of gym facilities.
7. Dissemination and implementation arrangements
7.1
The policy will be placed on the Trust intranet and its authorisation will be
recorded in the weekly Trust information bulletin.
7.2
BDU management teams will ensure that local gyms operate in
accordance with this policy.
7.3
Training for staff to support patients in the gym will be provided through
the Trust training department in response to the training needs analysis.
Training will be provided by staff identified by the steering group as being
competent to do so. These will usually be staff who have specific exercise
qualifications at an advanced level, or physiotherapists.
8. Compliance monitoring and policy development
8.1
A trust wide steering group will be set up to review the use of the gyms,
training requirements and incidents. This group will be responsible for
reviewing and amending the policy and updating the training as required.
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8.2
The steering group will be jointly led by Nicola Mirfin, Exercise Practitioner
and Richard Watterston, Physiotherapy Professional Lead. It will report to
the Medical Devices TAG.
9. Review and revision arrangements
9.1
The policy will be reviewed after one year, or before that if required, by the
steering group.
9.2
Previous versions of the policy will be archived according to Trust policy.
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Appendix A - Equality Impact Assessment
Date of Assessment: 9 March 2015
Equality Impact Assessment
Questions:
Evidence based Answers & Actions:
1
Name of the document that you are
Equality Impact Assessing
Trust Gym Policy
2
Describe the overall aim of your
document and context?
Who will benefit from this
policy/procedure/strategy?
This new policy is designed to bring all of the trustmanaged gyms into compliance with the Medical
Devices, Infection Control and Health & Safety
requirements and to standardise the training for the
staff across the trust.
3
Who is the overall lead for this
assessment?
Richard Watterston, Physiotherapy Professional
Lead
4
Who else was involved in
conducting this assessment?
Nicola Mirfin, Exercise Practitioner
5
Have you involved and consulted
service users, carers, and staff in
developing this
policy/procedure/strategy?
Information from key staff operating trust gyms and
the training.
What did you find out and how have
you used this information?
Continuing consultation with the low secure user
group. The policy is to bring gyms up to the technical
requirements required by H&S, Medical Devices and
Infection Control.
6
What equality data have you used to
inform this equality impact
assessment?
The policy has clarified the situation regarding
patient’s person weights in their own room, to comply
with the above and the least restrictions principle of
the MHA Code of Practice.
Consultations with the Trusts Wellbeing Steering
group, the Trust Gym Policy working party and trust
wide consultation.
7
What does this data say?
No issues identified
8
Taking into account the
information gathered
above, could this policy
/procedure/strategy affect
any of the following
equality group
unfavourably:
Yes/No
8.1
Race
No
8.2
Disability
No
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No
No impact. Gym programmes are all developed by
exercise specialists, patients are supervised by staff
assessed as being competent to do so. Where
required (and where the service employs them)
patients with disabilities will be supervised by
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Equality Impact Assessment
Questions:
Evidence based Answers & Actions:
registered physiotherapists or occupational
therapists.
8.3
Gender
No
8.4
Age
No
8.5
Sexual Orientation
No
8.6
Religion or Belief
No
8.7
Transgender
No
8.8
Maternity & Pregnancy
No
8.9
Marriage & Civil
No
No impact. All programmes are designed around
individuals
partnerships
8.10
Carers*Our Trust
n/a
requirement*
9
What monitoring arrangements are
you implementing or already have in
place to ensure that this
policy/procedure/strategy:-
Regular review by policy lead for continued
suitability, Overview by the Trust’s Drugs and
Therapeutic group and by the Trust’s Wellbeing
Steering Group
9a
Promotes equality of opportunity for
people who share the above
protected characteristics;
Yes
9b
Eliminates discrimination,
harassment and bullying for people
who share the above protected
characteristics;
Yes
9c
Promotes good relations between
different equality groups;
Yes
9d
Public Sector Equality Duty – “Due
Regard”
Have you developed an Action Plan
arising from this assessment?
Yes
10
11
N/A
Assessment/Action Plan approved
by
Signed:
Date: 21/09/15
Title: Physiotherapy Professional Lead
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Equality Impact Assessment
Questions:
12
Evidence based Answers & Actions:
Once approved, you must forward a
copy of this Assessment/Action Plan
to the Equality and Inclusion Team:
inclusion@swyt.nhs.uk
Please note that the EIA is a public
document and will be published on
the web.
Failing to complete an EIA could
expose the Trust to future legal
challenge.
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Appendix B - Checklist for the Review and Approval of Procedural Document
To be completed and attached to any policy document when submitted to EMT for consideration and
approval.
Title of document being reviewed:
1.
2.
Title
Is the title clear and unambiguous?
Y
Is it clear whether the document is a guideline,
policy, protocol or standard?
Y
Is it clear in the introduction whether this
document replaces or supersedes a previous
document?
Y
Rationale
Are reasons for development of the document
stated?
3.
4.
5.
6.
Yes/No/
Unsure
Y
Development Process
Is the method described in brief?
N
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?
N
Are the references cited in full?
N
Are supporting documents referenced?
N
Approval
Does the document identify which
committee/group will approve it?
Y
If appropriate have the joint Human
Resources/staff side committee (or equivalent)
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N/A
Comments
Title of document being reviewed:
Yes/No/
Unsure
approved the document?
7.
8.
9.
10.
11.
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 KPIs to
support the monitoring of compliance with and
effectiveness of the document?
Y
Is there a plan to review or audit compliance
with the document?
Y
Review Date
Is the review date identified?
Y
Is the frequency of review identified? If so is it
acceptable?
N
Overall Responsibility for the Document
Is it clear who will be responsible
implementation and review of the document?
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Y
Comments
Appendix C - Version Control Sheet
This sheet should provide a history of previous versions of the policy and changes made
Version
Date
Author
Status
Comment / changes
1
18/2/15
Physiotherapy
Professional Lead
Draft
Developed with a group of staff
responsible for trust gyms consisting of:
Simon Plummer, Pat Pope, Rod Newsome
and Kieran Walsh, physiotherapists; Nicola
Mirfin and Jonathon Coward, exercise
practitioners; Claire Girvan and Rebecca
Purvis, OT; Lisa Connor, practice
governance coach; Sue Hastewell-Gibbs,
General Manager; Roland Webb, H&S
Manager.
Circulated to general managers, IPC and
practice governance coaches for
comment.
1.2
9/2/15
Physiotherapy
Professional Lead
Draft
Amended following comments. Circulated
to the group and Inclusion team for final
comments.
1.3
26/3/15
Physiotherapy
Professional Lead
Final
Draft
Final comments and EIA added. Sent for
approval
1.4
23/6/15
Physiotherapy
Professional Lead
Expected
Final
Draft
Sent to EMT for approval but policy not
represented by author.
Points also raised by steering group
members.
SP has left the trust and replaced by RW
as Physiotherapy Professional Lead.
Steering group re-convened and version
1.4 produced.
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