Policy forthe provision of same sex accommodation final ratified version pdf format

Policy for the provision of same sex accommodation of 22

See the Intranet for the latest version. Version Number:- 1

DOCUMENT CONTROL PAGE

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Title: Policy for the Provision of Same Sex Accommodation

Version: 1 Reference Number:

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Supersedes: None

Description of Amendment(s):

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Originated By: Jane Grimshaw / Bernice Postlethwaite / Lynn Ashurst

Designation: Corporate Lead Nurse / Patient Partnership Manager / Lead Nurse: Privacy and Dignity

Modified by:

Designation:

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Approval by: Trust Operational Management Group Approval Date: 4

th September 2009

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All Patients All staff

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Issue Date: August 2009

Circulated by: Director of Nursing (Adults)

Issued to: All Managers with staff management responsibilities

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Review Date: August 2012

Responsibility of: Director of Nursing (Adults)



POLICY CONTROL PAGE (2) CIRCULATION DOCUMENT

Circulation List: Refer to section 7 - Dissemination and Implementation For Information:

Central Manchester University Hospitals NHS Foundation Trust is committed to promoting equality and diversity in all areas of its activities. In particular, the Trust wants to ensure that everyone has equal access to its services. Also that there are equal opportunities in its employment and its procedural documents and decision making supports the promotion of equality and diversity. Refer to section 8 for more detail on undertaking equalities impact assessment.

This document must be disseminated to all relevant staff, refer to section 10: Dissemination and Implementation

The Policy must be posted on the intranet: Date Posted:



1. Introduction 1.1 Central Manchester University Hospitals NHS Foundation Trust is committed to

respecting the privacy and dignity of its patients and the public. Provision of same-sex accommodation is a visible affirmation of the Trusts commitment to this issue.

1.2 The Chief Nursing Officer published a report ‘Privacy and Dignity – a report by the

Chief Nursing Officer into mixed sex accommodation in hospitals’ in 2007. Subsequently the NHS Institute for Innovation and Improvement published a good practice guide and self assessment checklist ‘Privacy and Dignity: The elimination of mixed sex accommodation’. This document outlines 11 key principles to support the achievement of good physical separation of the sexes in hospital accommodation.

Section Contents Page

1 Introduction 3

2 Purpose 4

3 Roles and Responsibilities 4

4 Definition of Same Sex Accommodation 5

5 Exempt Areas 5

6 Good Practice Guidance 5

7 Critical Care Environments 6

8 Recovery Units 7

9 Emergency Admissions 7

10 Elective Admissions 8

11 Day Treatment Areas 9

12 Day Surgery and Endoscopy Units 10

13 Children and Adolescents 10

14 Trans People and Gender Variant Children 11

15 Considerations for Gender Variant Children and Young People 13

16 Process and Escalation for Episodes of Mixed Sex Accommodation

13

17 Equality Impact Assessment 14

18 Consultation, Approval and Ratification Process 14

19 Dissemination and Implementation 15

20 Review, Monitoring Compliance with and the Effectiveness of Procedural Documents

16

21 Standards and Key Performance Indicators (KPI’s) 16

22 References and Bibliography 17

23 Associated Trust Documents 17

24 Appendices Appendix A - Equality Impact Assessment (EqIA)

18

Appendix B - Flowchart to Facilitate the appropriate placement of patients into Same-Sex Accommodation

21

Appendix C - Flowchart: Escalation Process for situations where Same-Sex Accommodation cannot be provided

22



1.3 Further recent guidance provided by NHS North West in March 2009 and the Chief

Nursing Officer (CNO) guidance for ‘Delivering Same Sex Accommodation’ (DSSA) May 2009 outlines the necessity to eliminate mixed sex accommodation within the Trust. There are a number of clinical areas where mixing of the sexes can be considered reasonable, however decisions should be based upon the needs of each individual patient, not the constraints of the environment, or the convenience of the staff. Divisions will be required to achieve the elimination of mixed sex accommodation through development of creative and flexible solutions whilst maintaining capacity and optimising patient flow. Initiatives may include:

• single sex wards

• single sex day case lists

• structural improvements to the clinical environment. 1.4 Promotion of privacy and dignity are reflected in a number of the core standards

measured by the Care Quality Commission as part of the Annual Health Check. 1.5 Elimination of mixed sex accommodation will support the Trust in demonstrating

compliance with these standards. 1.6 Nationally patient feedback identifies segregation of the sexes as being important in

maintaining privacy and dignity. The Trust views elimination of mixed sex accommodation as one of a number of initiatives to improve the patient experience, through maintaining the individuals’ privacy and dignity.

1.7 The principles of privacy and dignity are just as important children and young people

as they are for adults. However, we know that many young people find good peer support from sharing with others of their own age or sex. Often, this outweighs their concerns about mixed sex rooms. Where possible, we advise that adolescents should be able to choose whether they share or not.

2. Purpose

The purpose of the policy is to detail the Trust’s approach to the achievement and maintenance of same sex accommodation within all clinical areas and the escalation policy where exemptions occur.

3. Roles and Responsibilities 3.1 Board of Directors

The Board of Directors have overall responsibility to ratify and implement this policy, ensuring that appropriate resources are available

3.2 Executive Director of Patient Services / Chief Nurse The Executive Director of Patient Services / Chief Nurse will be the executive responsible for overseeing the implementation of the policy.

3.3 Directors of Nursing

The Directors of Nursing will be responsible for ensuring the implementation of the policy through the nursing and midwifery workforce.



3.4 Clinical Heads of Division The Clinical Heads of Division will be responsible for ensuring the implementation of the policy through the medical staffing workforce.

3.5 Divisional Directors / Directorate Managers / Heads of Nursing The Divisional Directors, Directorate Managers and Heads of Nursing will be responsible for ensuring that arrangements and processes are in place to support the implementation of the policy via their operational structures and local policies, across all clinical and non-clinical areas within the Divisions

3.6 Lead Nurses

The Lead Nurses will be responsible for the monitoring of compliance within the policy and appropriate actions as required.

3.7 Ward Managers / Team Leaders

Ward Managers will be responsible for ensuring that all their staff are aware of this policy and ensure compliance with policy in the clinical areas.

3.8 All Trust Staff All Trust Staff will be responsible for the implementation and compliance of the policy.

4. Definition of Same Sex Accommodation Same sex accommodation can be provided in:

• single sex wards i.e. the whole ward is occupied by men or women but not both

• single rooms with adjacent single sex toilet and washing facilities, preferably en-suite

• single room accommodation within mixed wards i.e. bays or rooms which accommodate either men or women, not both; with designated single sex toilet and washing facilities preferably within or adjacent to the bay or room.

5. Exempted Areas 5.1 There are no exemptions from the need to provide high standards of privacy and

dignity. However, it is recognised that in some circumstances it might be appropriate to have patients in mixed sex accommodation for clinical reasons.

5.2 These clinical areas to be considered include:

• Intensive Care Units*

• High Dependency Units*

• Day Treatment Areas*

• Emergency Departments / Admission Units*

• Many young people find great comfort and peer group support from sharing with others of their own age. Often, this outweighs their concerns about mixed sex rooms.

For all other clinical areas there are no exemptions to the provision of same sex accommodation for patients.



6 Good Practice Guidance

Compliance with provision of same sex accommodation can be achieved through:

6.1 Separate, clearly labelled, male and female toilets and washing facilities which are available within the ward or department.

6.2 Toilet and washing facilities which are located within, or close to the patient’s room or bay.

6.3 Patients must be able to reach toilets and washing facilities without the need to pass through areas occupied by members of the opposite sex.

6.4 Where patients pass near to areas occupied by members of the opposite sex, adequate screening such as opaque glazing or blinds/curtains at windows and doors are to be closed.

6.5 Where assisted bathrooms remain unisex, appropriate facilities are to be provided to

uphold the privacy and dignity of all patients who use them such as privacy curtains.

6.6 All partitions separating men and women’s areas should be full-height, rigid and fixed to the building structure. They should be robust enough to prevent casual overlooking and overhearing.

6.7 Curtains create privacy around the bed space, or add an extra layer of protection within a bathroom to allow staff to enter without exposing the patient. They are not suitable for separating men and women. As a guide: no more than the patient’s shin should be visible underneath a curtain. This will be no higher than about 30 centimetres or 12 inches.

7. Critical Care Environments 7.1 High standards usually involve a presumption that men and women do not have to

sleep in the same room, nor use mixed bathing and WC facilities. These presumptions are intended to protect patients from unwanted exposure, including casual overlooking and overhearing.

7.2 Patients should not have to pass through opposite sex areas to reach their own facilities.

7.3 On occasion, however, a minority of patients may have a clinical condition which requires immediate access to potentially life-saving treatments which can only be delivered within critical care environments. At these points in a patient’s journey, access to and treatment within appropriate locations is paramount.

7.4 In these situations, mixing of the sexes is justified as long as the following general

key principles are incorporated into the care pathway:

• Decisions are based on the needs of the individual patient whilst in critical care environments, and their clinical needs will take priority.



• When a patient’s survival and recovery depend on the presence of high tech equipment and very specialist care, the requirement for full segregation clearly takes a lower priority. This does not mean that an attempt at segregation is not necessary. At the very least, staff should consider whether it is possible to create male and female bays or “ends” within a unit.

• Decisions should be reviewed as the patient’s clinical condition improves and should not be based on constraints of the environment, or convenience of staff.

• The risks of clinical deterioration associated with moving patients within critical care environments to facilitate segregation must be assessed.

• Where mixing of the sexes does occur, there should be levels of staffing so that each patient can have their modesty constantly maintained by nursing staff. This will usually mean a constant nurse presence within the room or bay.

• Where possible (for instance for planned post-operative care) patient preference should be sought, recorded in the medical notes and where possible respected. Ideally, this should be in conjunction with relatives or loved ones.

8. Recovery Units

8.1 The same principles apply to recovery units where patients are cared for immediately following surgery, before transfer to the ward.

8.2 Whilst separate male and female recovery units are not compulsory, segregation should remains the ideal standard. In these areas consideration should be given to the following:

• Creating male and female bays or “ends” within the unit.

• Levels of observation and nursing attendance should mean that all patients can have their modesty preserved whilst unconscious, semi-conscious or sedated.

9. Emergency Admissions 9.1 There are no exemptions from the need to provide high standards of privacy and

dignity. This applies to all areas, including when admission is unplanned.

9.2 High standards usually involve the principle that men and women do not have to sleep in the same room, nor use mixed bathing and WC facilities.

9.3 These principles are intended to protect patients from unwanted exposure, including casual overlooking and overhearing, Patients should not have to pass through opposite sex areas to reach their own facilities.

9.4 It is recognised that in some emergencies, mixing of the sexes is justified. Decisions

should be based on the needs of each individual patient, not the constraints of the environment, or the convenience of staff.



9.5 This means that mixing must be justifiable for all patients in the room. In these situations the following general principles should be considered by staff:

• When a patient’s survival and recovery depend on rapid admission, the requirement for full segregation clearly takes a lower priority, but this does not imply a blanket exemption for all emergency admissions. Nor does it imply a blanket exemption for admissions units.

• Clinical need must be judged for each individual patient. If a patient is admitted into a multi-bed room, then either all patients must be the same gender, or mixing must be clinically justified for all patients in the room, not just the newly-admitted one.

• “Admission unit” includes all units where a patient may be admitted for assessment, treatment or observation, pending a final decision on treatment. This covers clinical decision units, emergency admission wards, observation wards and medical assessment units. Admissions units should be capable of delivering segregation as the norm for patients.

• Clearly, patient safety is paramount, but the requirement for segregation should not be ignored. It should be demonstrably possible for the large majority of emergency patients to have their clinical needs met within segregated accommodation.

• Decisions should be based on the needs of each individual patient, not the constraints of the environment, or the convenience of staff.

• Greater segregation should be provided where patients’ modesty may be compromised (e.g. when wearing hospital gowns/nightwear, or where the body (other than the extremities) is exposed.

• Greater protection should be provided where patients are unable to preserve their own modesty (for example when semi-conscious or sedated).

• Patient preference should be sought, recorded and where possible respected. Ideally, this should be in conjunction with relatives, carers or loved ones.

• The reasons for mixing, and the steps being taken to put things right should be explained fully to the patient and her/his family and friends. Staff should make clear to the patient that the Trust considers mixing of sexes to be the exception, never the norm and this should be documented in the patient’s medical notes.

• Where patients cannot be immediately admitted to the “right bed” (i.e. one in the right specialty, with same-sex accommodation) then the final placement decision should weigh the benefits and disadvantages of each available option. Wherever possible, the patient or their family should be consulted.

• Where mixing is unavoidable, transfer to same-sex accommodation should be effected as soon as possible. Only in the most exceptional circumstances should this exceed 24 hours.



10. Elective Admissions

10.1 Elective patients are to be accommodated in either single rooms, single sex wards or single sex bays/rooms within mixed wards.

10.2 If any parts of the ward that an elective patient is to be admitted are shared between male and female the patient must be informed in writing prior to admission. If the patient is unable to read, they must be informed verbally and this is to be documented.

10.3 Patients are able to request alternative accommodation, or where the accommodation offered is mixed, ask for an alternative admission date to an environment that is same sex.

10.4 Those patients who ask for an alternative admission date are to receive the offer of a date within one month of the original date

11. Day Treatment Areas

11.1 There are no exemptions from the need to provide high standards of privacy and dignity. This applies to all areas, including day treatment areas. However, we recognise that in some day treatment areas, mixing of the sexes can be reasonable, or even desirable.

11.2 Examples of “day treatment areas” include, amongst others:

• Renal dialysis units

• Day surgery units **(see guidance: page 10)

• Endoscopy units ** (see guidance: page 10)

• Chemotherapy units 11.3 Decisions should be based on the needs of each individual patient, not the

constraints of the environment, or the convenience of staff 11.4 Greater segregation should be provided where patients’ modesty may be

compromised (e.g. when wearing hospital gowns/nightwear, or where the body (other than the extremities) is exposed.

11.5 Greater protection should be provided where patients are unable to preserve their

own modesty (e.g. following recovery from a general anaesthetic or when sedated).

11.6 Decisions about segregation can be made at the discretion of staff dependant upon the patient’s circumstances. For instance, in a renal dialysis unit, where all patients are well-established on treatment, wear their own clothes and have formed personal friendships, mixing may be a good thing. By contrast, a new dialysis patient, with a femoral catheter and wearing a hospital gown, should be able to expect a much higher degree of privacy.

11.7 Similar considerations apply wherever treatment is repeated, especially where

patients may derive comfort from the presence of other patients with similar conditions. Thus, for instance, it may be appropriate to nurse a mixed group of patients together as they receive regular blood transfusions.



Likewise, it is clearly reasonable for both men and women to attend an elderly care day hospital together, as long as toilet and bathroom facilities are separate, and very high degrees of privacy and segregation are maintained during all clinical or personal care procedures.

11.8 Patient preference should be sought, recorded in the medical notes and where

possible respected. Ideally, this should be in conjunction with relatives, carers or loved ones.

11.9 The reasons for mixing, and the steps being taken to put things right should be

explained fully to the patient and her/his family and friends. Staff should make clear to the patient that the Trust considers mixing of sexes to be the exception, never the norm and this should be documented in the patient’s medical notes

12. Day Surgery and Endoscopy Units

12.1 The presumption of single sex accommodation applies in day surgery units,

especially those where a patient’s stay can be up to 23 hours 59 minutes. The exception might be where very minor procedures are being undertaken – e.g. “lumps and bumps” on the hand or foot. If the patient is in a hospital gown, and may have difficulty preserving their own modesty due to sedation or anaesthesia, then segregation should be the norm.

13. Children and Adolescents 13.1 There are no exemptions from the need to provide high standards of privacy and

dignity. This applies to all areas, including children’s and young people’s units.

13.2 It is recognised that for many children and young people, clinical need and age and stage of development may take precedence over gender considerations and mixing of the sexes is reasonable, or may even be preferred.

13.3 There is evidence that many young people find greater comfort from sharing with

others of their own age and often, this outweighs their concerns about mixed sex rooms. Young people should be given the choice.

13.4 Children and in particular young people need special consideration. The hospital

standard of the National Service Framework (NSF) for Children and Young People requires them to be treated in accommodation that meets their needs for privacy and is appropriate for their age and stage of development.

13.5 Under the NSF, segregation by age is a more important issue than segregation by

gender. This is a particular issue for young people, who want primarily to be with patients of similar age and interests to meet their need for social interaction. In addition, they want to be able to choose between being in a single or a mixed sex environment and should be provided with the opportunity to do so. Patient preference must be recorded in the medical notes.



13.6 Using these principles allows staff to make sensible decisions for each patient. This may mean segregating on the basis of age rather than gender, but such decisions must be demonstrably in the best interest of each patient. Flexibility may be required – for instance patients might prefer to spend most of their time in mixed areas, but to have access to single gender spaces for specific treatment needs or to undertake personal care. Such flexibility is encouraged. It is not acceptable to apply a blanket approach that assumes mixing is always excusable.

13.7 The care of young people requires careful consideration, ensuring their privacy and

dignity needs are met whilst meeting their other needs including safeguarding. 13.8 Decisions should be based on the clinical, psychological and social needs of the child

or young person, not the constraints of the environment, or the convenience of staff.

13.9 Healthcare professionals should be able to be flexible to the individual

children’s/young peoples needs and where it is impossible to exactly provide what the child or young person desires because of clinical need, accommodation to meet these needs should be considered (e.g. the young person needing private space during the day for whatever reason).

13.10 In children’s units parents are encouraged to visit freely and stay overnight. This may

mean that adults of the opposite sex share sleeping accommodation with children. Care and consideration must always be given to the parents to ensure that they are not embarrassed in any way, and also that the children are not compromised in their care by any member of the opposite sex being resident.

13.11 In children’s and adolescent areas the following principles should be considered by

staff:

• Washing & WC facilities need not be designated as same-sex as long as they accommodate only one patient at a time, and can be locked by the patient (with an external override for emergency use only).

• Privacy & dignity should be maintained whenever children and young people’s modesty may be compromised (e.g. when wearing hospital gowns/nightwear or where the body (other than the extremities) is exposed, or they are unable to preserve their own modesty (for example following recovery from a general anaesthetic or when sedated)

• The child or young person’s preference should be sought, recorded in the medical notes and where possible respected.

• Where appropriate the wishes of the parents should be considered, but in the case of young people their preference should prevail.

14 Trans People and Gender Variant Children

14.1 Transsexual people, that is, individuals who have proposed, commenced or completed reassignment of gender, enjoy legal protection against discrimination.



In addition, good practice requires that clinical responses be patient-centred, respectful and flexible towards all transgender people who do not meet these criteria but who live continuously or temporarily in the gender role that is opposite to their natal sex.

14.2 Trans people should be accommodated according to their presentation: the way they

dress, and the name and pronouns that they currently use. 14.3 This may not always accord with the physical sex appearance of the chest or

genitalia; 14.4 It does not depend upon their having a gender recognition certificate (GRC) or legal

name change; 14.5 It applies to toilet and bathing facilities (except, for instance, that pre-operative trans

people should not share open shower facilities); 14.6 Views of family members may not accord with the trans person’s wishes, in which

case, the trans person’s view takes priority.

14.7 Those individuals who have undergone full-time transition should always be accommodated according to their gender presentation. 14.8 Different genital or breast sex appearance is not a bar to this, since sufficient privacy can usually be ensured through the use of curtains or by accommodation in a single side room adjacent to a gender appropriate ward.

14.9 This approach may only be varied under special circumstances for example:

• Where, for instance, the treatment is sex-specific and necessitates a trans person being placed in an otherwise opposite gender ward. Such departures should be proportionate to achieving a ‘legitimate aim’, for instance, a safe nursing environment.

• When a trans man is having a hysterectomy in a hospital, or hospital ward that is designated specifically for women, and no side room is available. The situation should be discussed with the individual concerned and a joint decision made as to how to resolve it. At all times this should be done according to the wishes of the patient, rather than the convenience of the staff

• Where admission/triage staffs are unsure of a person’s gender, they should, where possible, ask discreetly where the person would be most comfortably accommodated. They should then comply with the patient’s preference immediately, or as soon as practicable.

• If patients are transferred to a ward, this should also be in accordance with their continuous gender presentation (unless the patient requests otherwise).

• If upon admission, it is impossible to ask the view of the person because he or she is unconscious or incapacitated then, in the first instance, inferences should be drawn from presentation and mode of dress.



• No investigation as to the genital sex of the person should be undertaken unless this is specifically necessary in order to carry out treatment.

• In addition, it is important to take into account that immediately post-operatively, or while unconscious for any reason, those trans women who usually wear wigs, are unlikely to wear them in these circumstances, and may be ‘read’ incorrectly as men. Extra care is therefore required so that their privacy and dignity as women is appropriately ensured.

• Trans men whose facial appearance is clearly male, may still have female genital appearance, so extra care is needed to ensure their dignity and privacy as men.

For further information please visit the following website: http://www.gires.org.uk/assets/trans-rights.pdf section 1.4, pp 9, 10

15. Considerations for Gender Variant Children and Young People 15.1 Gender variant children and young people should be accorded the same respect for

their self-defined gender as are trans adults, regardless of their genital sex.

15.2 Where there is no segregation, as is often the case with children, there may be no requirement to treat a young gender variant person any differently from other children and young people. Where segregation is deemed necessary, then it should be in accordance with the dress, preferred name and/or stated gender identity of the child or young person.

15.3 In some instances, parents or those with parental responsibility may have a view that

is not consistent with the child’s view. If possible, the child’s preference should prevail even if the child is not Gillick competent.

15.4 More in-depth discussion and greater sensitivity may need to be extended to

adolescents whose secondary sex characteristics have developed and whose view of their gender identity may have consolidated in contradiction to their sex appearance. It should be borne in mind that they are extremely likely to continue, as adults, to experience a gender identity that is inconsistent with their natal sex appearance so their current gender identity should be fully supported in terms of their accommodation and use of toilet and bathing facilities.

15.5 It should also be noted that, although rare, children may have conditions where genital appearance is not clearly male or female and therefore personal privacy may be a priority. 16 Process and Escalation for Episodes of Mixed-Sex Accommodation 16.1 Actions should focus on maximising privacy and dignity, and reassuring patients that

everything possible has been done to avoid use of mixed sex accommodation. The issue should be escalated through the Division to explore alternative accommodation for the patient prior to utilisation of mixed sex accommodation. During hours this should be escalated to the appropriate Matron/Lead Nurse and out of hours to the Senior Nurse/relevant hospital bleep holder.



16.2 A full explanation and apology must be provided to the patient, relatives or carers where same sex accommodation cannot be provided.

16.3 This applies to those patients:

• who should automatically be allocated single sex accommodation

• where a choice of same sex accommodation should be offered but is unavailable

• Where segregation is considered desirable by staff to maintain privacy and dignity, but is unavailable. This should be documented in the patient’s medical notes. Staff should take extra care during this time to safeguard privacy, particularly in sleeping and sanitary areas.

16.4 Any occurrence of mixed sex accommodation other than the exempt areas listed in

section 4.2 must be reported as an untoward incident on the Trust Incident Reporting System. The incident should be graded using the Trust matrix and according to the level of harm to the patient/s, damage to the reputation of the organisation and potential risk of reoccurrence.

16.5 Every effort must be made to resolve the issue through provision of same sex

accommodation for the patient as soon as possible Where the issue is not resolved within 24hours the incident level must be upgraded and escalated to the Head of Nursing and Assistant Director of Nursing/Director of Nursing in hours and out of hours to the Duty Manager.

16.6 Patients, relatives and carers need to be informed about actions that are being taken

to resolve the problem and documented in the patient’s medical notes. For further guidance see: Appendix B: Flowchart to facilitate the appropriate placement of patients into same-sex accommodation Appendix C: Flowchart: Escalation Process for situations where same-sex accommodation cannot be provided

17. Equality Impact Assessment 17.1 Central Manchester and Manchester University Hospitals NHS Trust is committed to

promoting equality and diversity in all areas of its activities. In particular, the Trust wants to ensure that everyone has equal access to its services. Also that there are equal opportunities in its employment and its procedural documents and decision making supports the promotion of equality and diversity.

17.2 The initial Equality Impact Assessment (EqIA) – Assessment of Policy for Relevance

for Promotion of Equality – Initial EqIA is found at Appendix A. This must be completed and submitted to the Equality and Diversity Department for ‘Service Equality Team Sign Off’

17.3 Please contact the Equality and Diversity Department if you have any queries on

0161 276 6897 or [email protected].



18 Consultation, Approval and Ratification Process

18.1 Consultation and Communication with Stakeholders

The main internal stakeholders for this policy are the Trust’s Clinical Divisions, Corporate Services and Facilities Management. All internal stakeholders will be given an opportunity to comment before ratification.

18.2 Policy Approval Process Draft policy for comment and approval will be circulated to the following: Director of Patient Services / Chief Nurse Director of Nursing (Adults) Director of Nursing (Childrens) Head of Midwifery Divisional Directors Associate Director of Patient Services Associate Director of Estates and Facilities Associate Director for Clinical Governance Head of Clinical Audit Head of Legal Services Health and Safety Advisor Emergency Planning Officer Assistant Directors of Nursing Heads of Nursing Lead Nurses/Modern Matrons Ward Mangers Patients and Public

18.3 Ratification Process When approved the Trust Board will ratify the policy

19. Dissemination and Implementation 19.1 Dissemination

When ratified the policy will be posted onto the Trust Wide Internet site and also the Trusts website

The policy availability and information will be communicated by or to the following,

Trust wide Core Team Brief Individual Divisional governance news letters Clinical governance forums or equivalent are notified Annual clinical audit and Risk management fair via poster presentation



The following will be notified of the ratification of this policy:

Director of Patient Services / Chief Nurse Director of Nursing (Adults) Director of Nursing (Childrens) Director of Nursing (Midwifery) Divisional Directors Associate Director of Patient Services Associate Director of Estates and Facilities Associate Director for Clinical Governance

Head of Clinical Audit Head of Legal Services Health and Safety Advisor Emergency Planning Officer Assistant Directors of Nursing Divisional Heads of Nursing Lead Nurses/Modern Matrons Ward Managers

19.2 Implementation of Procedural Documents

Progress on implementation of the single sex accommodation policy will be raised and reported to the Operational Risk Management committee by the Director of Nursing (Adults). Modern Matrons and Ward Managers will deliver local training regarding the implementation of the policy in the clinical areas.

20. Review, Monitoring Compliance With and the Effectiveness of Procedural

Documents

The policy will be monitored for performance and effectiveness in the following ways:

• Internal review by self assessment against the Standards for Better Health Core Development Standards on an annual basis

• Evaluate patient perceptions of privacy and dignity through use of Dr Foster patient experience tracker (PET)

• Annual internal review by Clinical Audit department

• Ongoing Matron Ward Round Audits

• Annual reporting based on Divisional review by annual reports

• Review of incident reporting on a monthly basis

• Feedback from annual Patient Environment Action Team assessment 20.1 Process for Monitoring Compliance and Effectiveness

• Clinical audit standards methodology will be used for annual audit

• Matron Ward Audit methodologies will be used to capture key areas for the implementation of the policy.

• Evaluation of incident reports for non compliance within the policy

• Review of complaints and PALS data for the patient experience

• Implementation of patient experience tracker information to record real time experiences for single sex accommodation in the clinical areas.



21 Standards and Key Performance Indicators ‘KPIs’

21.1 This policy will be reviewed every three years or when there are significant changes

to the document

21.2 The policy will be available on the Trust intranet and website

21.3 Audit reports and reports of compliance will be tabled at the Operational Managers Group

22. References and Bibliography Department of Health (2006), Dignity in Care

Chief Nursing Officer (2007), Mixed sex Accommodation in Hospitals Healthcare Commission (2007), Caring for Dignity Institute for Innovation and Improvement, Good Practice Guidance and Self Assessment Checklist NHS North West (2009), Eliminating Mixed sex Accommodation Chief Nursing Officer (2009), Delivering Same Sex Accommodation

23. Associated Trust Documents

Incident Reporting and Serious Incident Policy 2008 Complaints Reporting Policy 2008 Infection Control Policy 2008 Business Continuity Planning Guidance Action for Equality Estates and Facilities Strategy

24. Appendices Appendix A: Equality Impact Assessment (EqIA) – Assessment of Policy for Relevance for

Promotion of Equality – Initial EqIA Appendix B: Flowchart to facilitate the appropriate placement of patients into same-sex accommodation Appendix C: Flowchart: Escalation Process for situations where same-sex accommodation cannot be provided



Equality Impact Assessment (EqIA) – Assessment of Policy for Relevance for Promotion of Equality – Initial EqIA Appendix A (Please complete electronically)

1 Division Corporate Services

2 Directorate

3 Department/ Service

4 Policy Policy for the provision of single sex accommodation within clinical and non-clinical areas

Divisional Director/Head of Service Gill Heaton

5 Assessment Completed By a) Name b) Position Jane Grimshaw Corporate Lead Nurse Berenice Postlethwaite Patient Partnership Manager

6 Lead Person Jane Grimshaw Contact No. 64336

Position Corporate Lead Nurse Date Completed

Signature

7 Does the Policy Benefit or have an Impact upon either Staff, the Public or Both?

Yes X No Not Sure



11 Reasons for Non-Applicability

Area Reasons Age

Is there a Differential Impact?

9 The Level of Concern?

8a) Is there any information or reason to believe that the operation of this policy would or does affect groups differently? Answer: Yes 20 No 0 X Not Applicable 0 Not Sure 12

8b) How much information or evidence is there? Answer: None 2 Little 1 Some 3 Substantial 5

Has there been any concern expressed by the public or staff about the operation of this policy?

Answer: None 2 Little 1 Some 3 Substantial 5

10 Total Scores

Staff Public Staff Public Staff Public Staff Public Age 0 0 Disability 0 0 Gender/Sex 0 0 Race and Ethnicity 0 0 Religion and Belief 0 0 Sexuality 0 0

Sub Total 0 0

Total 0



Disability

Gender /Sex

Race and Ethnicity

Religion and Belief

Sexuality

12 Priority

Total Score 0 Priority Low

13 Service Equality Team Sign Off

Name

Position

Signature

Date of Sign Off

Priority

Low 0-9

Medium 10-29

High 30+

EqIA Registration No. IP



No Does the patient need to be placed in a specific specialty for clinical reasons

Yes

Bed identified in an appropriate

specialty ward and compliant as same sex accommodation

Yes

Bed Manager liaises with the ward to identify options to move additional patients to create same sex capacity within the relevant clinical specialty. If not, liaise with referring doctor to ascertain if patient can out-lie from

preferred specialty. Consider the option of other patients who may be more suitable to out-lie

Escalate the situation to Matron/Lead Nurse in-hours and the Senior Nurse/Hospital bleep holder out-of-hours.

Ensure that all possibilities have been explored, rather than placing patient in mixed sex accommodation

Can patient be appropriately placed in same sex accommodation?

For guidance: refer to the provision of same sex accommodation policy Follow process identified in Appendix C – Escalation Process for situations where same sex accommodation cannot be provided

Yes

No

No

Place Patient

Flowchart to facilitate the appropriate placement of patients into same-sex accommodation

Can same sex accommodation be facilitated within any

clinical specialty?

Bed requested

No

No

Appendix B



Ward staff must escalated the situation to the Matron/Lead Nurse

Lead Nurse/Senior Nurse must give an apology and full explanation to the patient and their relatives regarding

all that is being done in an attempt to resolve the situation.

Where the issue is not resolved within 24hours the incident level must be upgraded to level 4

Escalation Process for situations where same-sex accommodation cannot be provided

Actions to be taken in the event that a patient cannot be appropriately placed in same sex accommodation

Ward staff must complete an incident form

Matron/Lead Nurse must escalated the situation to the Head of Nursing and the Directorate Manager in-hours and to the Senior Nurse/Hospital bleep holder and Duty

Manager out-of-hours

Situation must be reviewed at 4-hourly intervals with the Bed Manager/ Patient Pathway Co-ordinator and this review must

be documented and discussed with the patient

Every effort must be made to resolve the issue as soon as possible

Head of Nursing/Lead Nurse must escalated the situation to the Assistant Director of

Nursing/Director of Nursing and the Divisional Director in-hours and to the Senior

Nurse/Hospital bleep holder and Duty Manager out-of-hours

Appendix C

Policy forthe provision of same sex accommodation final ratified version pdf format

Health & Medicine

Transcript of Policy forthe provision of same sex accommodation final ratified version pdf format