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DELIVERING SINGLE SEX ACCOMMODATION (DSSA) POLICY

Version 8

Name of responsible (ratifying) committee Trust Governance and Quality Committee

Date ratified 09 November 2017

Document Manager (job title) Lead Nurse for DSSA

Date issued 11 December 2017

Review date 10 December 2020

Electronic location Clinical Policies Policy for the Management of Adverse Incidents and Related Procedural Documents Near Misses Key Words (to aid with searching) Privacy and Dignity

Version Tracking Version Date Ratified Brief Summary of Changes Author 8 09.11.2017 Updated guidance for use of screens L.Hall 7 09.03.2017 Updated guidance for Day Units when opened as L. Hall escalation areas and RHCU for level 1 patients. RAG Breach ratings added for each area. Electronic location changed to Clinical Policies 6 22.03.2016 Updated quick reference flowchart and guidance for L. Hall transgender, ITU and recovery patients. 5 01.02.2014 Updated references J Sprack

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 1 of 50 CONTENTS

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 2 of 50 QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural documents.

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

• Mixed sex accommodation will be eliminated, except where it is in the best interests of the patient or reflects their personal preference.

• A breach occurs at the point a patient is admitted to mixed sex accommodation outside of the terms of this policy.

• The specialty matron (in hours), out of hours the Duty Matron or Duty Hospital Manager must be informed of the potential breach prior to the occurrence.

• All actions must be taken to avoid a breach and if not feasible, Kwick Screens must be used to manage the breach, segregating the females and males to promote privacy and dignity. Patient safety must be maintained when using screens and appropriate action taken to ensure this.

• If used effectively Kwick Screens will meet the standards required within the policy to prevent a breech. This will be discussed and determined when conducting the RCA and investigation. ` • If a breach occurs the numbers of patients affected must be declared at the next trust operational meeting by the patient flow manager for the specialty involved

• A breach form must be completed and a copy sent to the DSSA Lead Nurse for adults or Head of Nursing for Women and Children’s CSC if involving a young person.

• Patient to receive a personal visit from their CSC management team and a letter of apology (Appendix 1)

• Reported breach patients to be moved to single sex facilities within 24hrs

• A Safety Learning Event form must be submitted initially graded as an “amber” incident and a Single Sex Breach RCA completed. The CSC where the breach occurred are responsible for arranging a 48 hour panel chaired by the Director or Deputy Director of Nursing.

• Further details on managing emergency and specialty specific patients are within Section 8.

To Illustrate the Process

 Decision to admit wrong gender patient made  Escalate to Matron to search for alternatives  Escalate to Duty Hospital Manager who will inform the On Call Director  Written apology to be given to the patient (Appendix 1)  Safety Learning Event form to be completed by CSC  Specialty to complete IMR/RCA immediately (Appendix 2)  Copies emailed to Lead Nurse for DSSA with 48hours  CSC to organize panel to agree classification of breach prior to declaring  Once agreed, Lead Nurse DSSA to upload details on G drive  Lead Nurse DSSA to include in monthly report to commissioners

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 3 of 50 1. INTRODUCTION This policy details the requirements for the provision of treatment and care for patients in single sex facilities. The Trust maintains a single sex policy, which has a ‘zero’ tolerance for mixed sex accommodation across the Trust, and outlines the action and escalation required when a situation exists. All patients should be nursed in single sex accommodation, unless a young person expresses a preference to be cared for in a mixed bay or specialised or urgent care for the patient may take priority over ensuring same sex accommodation.

There are a small number of circumstances where mixing can be justified but these are few and mainly confined to patients who need highly specialised care, such as that delivered in critical care units.

The Department of Health recognises that children uniquely benefit from same age accommodation and this needs to be balanced with the need for same sex accommodation.

There are good reasons why children and young people are grouped together according to age rather than gender. What is important is taking into account their physical, psychological, clinical and social needs.

“ Children under 16 yrs. should not be cared for on adult ward, but on wards that are appropriate for their age and stage of development. Actual age is less important than the needs and preferences of the individual child or young person. In particular, the needs of the adolescents require careful consideration. In general, adolescents prefer to be located alongside other people of their age. The care of young people should be reviewed in the particular circumstances of each hospital, to make sure that their separate needs, including for safeguarding, are recognised and met” (C and YP Health Outcome Report 2013)

2. PURPOSE This policy outlines the processes for ensuring that patients are nursed in single sex facilities, and outlines the action and escalation required if there is a potential to breach the Trust’s single sex policy.

Non-compliance or breaches are required to be reported nationally via the Unify2 system, to the Commissioners and to provide assurance with PLACE and the Care Quality Commissions requirements.

3. SCOPE  This relates to all ward areas and departments accommodating in-patients, with the requirement to work towards the principles of single sex accommodation in specialist or urgent care areas.  The policy applies to all staff.  Breaches will be declared in a timely way as soon as a patient is admitted into a bay of other sex patients and will include all affected patients, i.e. those within the bay. (The policy will be audited on a monthly basis)

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain on-going patient and staff safety’

4. DEFINITIONS

These definitions are adopted from the Chief Nursing Officer and Deputy NHS Chief Executive letter (2010). For clarity, further detailed definitions relating to emergency, day Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 4 of 50 treatment, Critical Care, Children and Young People in-patient wards and gender variant children are within Section 7 in this policy.

4.1 Single Sex Accommodation and Facilities: Patients should not normally have to share sleeping accommodation, overlook accommodation of the opposite sex or share toilet or wash facilities with members of the opposite sex except children if this is their preference. This applies to all areas of hospital care.

4.2 Types of Breaches

i Breaches of sleeping accommodation A breach occurs at the point a patient is admitted to mixed sex accommodation outside of the terms of this policy. All patients affected by the breach, not just the patient who initiated the breach, need to be reported nationally via Unify 2. Individual patient names and NHS numbers must be used in order to track the commissioning location.

ii Breaches of bathroom accommodation A breach occurs at the point patients of the opposite sex use the same bathroom facilities. To prevent this, bathroom facilities should be clearly labelled as single use only and be located near to the sleeping accommodation for the same sex.

iii Breaches that involve patients having to pass through, or alongside sleeping accommodation of the opposite sex to reach bathroom facilities for their own sex.

A breach occurs if patients have no alternative but to pass through, or alongside sleeping accommodation of the opposite sex, to reach bathroom facilities for their own sex. This can be prevented be clearly labelling facilities as single sex and advising patients on admission which facilities are dedicated for their use. Partitions can be used to promote privacy and dignity, particularly in escalation areas where facilities have not been designed for inpatients.

If facility breaches cannot be avoided due to estate issues then an action plan must be devised to resolve the issues as a priority.

All types of breaches will be reported via a Safety Learning Event and monitored through the routine quality contract monitoring meetings with commissioners and local action plans.

4.3 The Use of Partitions/Screens The DOH guidance FAOs states it is acceptable to use partitions to provide single sex accommodation providing they meet the following criteria:  All partitions separating men and women's areas should be full-height, rigid and fixed to the building structure.  Full-height partitions do not have to be fixed to the ceiling if this would cause problems in areas with high ceilings such as old Nightingale wards, or get in the way of air flow or lighting.  Partitions should be high enough to make patients feel as if they are in a separate room

 All actions must be taken to avoid a breach and if not feasible, Kwick screens must be used to manage the breach, segregating the females and males to promote privacy and dignity. Patient safety must be maintained when using screens and appropriate action taken to ensure this.

 If used effectively Kwick Screens will meet the standards required within the policy to prevent a breech. This will be discussed and determined when conducting the RCA and investigation.

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 5 of 50 5. DUTIES AND RESPONSIBILITIES

5.1 Specialty Matron (within hours)  The CSC management team must be informed prior to any patient being placed in mixed sex accommodation to ensure that all other alternatives are explored (Duty Matron and out of hours Duty Hospital Manager).  Patients who by exception are placed in mixed sex accommodation and those affected should have a breach report completed (Section 8) and be declared at the next operational meeting by the patient flow coordinator.  An alternative single sex facility identified as soon as possible and at a maximum within 24 hours.  A Safety Learning Event form must be submitted initially graded as an “amber” incident and a Single Sex Breach Root Cause Analysis completed. The CSC where the breach occurred are responsible for arranging a 48 hour panel chaired by the Director or Deputy Director of Nursing to agree if a breach has occurred and any learning to prevent this happening again.  All patients who are placed in mixed sex accommodation should receive an apology and explanation from the CSC management team who will be alerted prior to the event. A root cause analysis must be commenced by the specialty.

5.2 Duty Hospital Manager (Out of Hours)  The On Call Director must be consulted prior to the event and all options explored to prevent a mixed sex  The DHM must submit a safety Learning Event and enter the patients details into the specific spread sheet on the G drive  The breach must be declared on the operations report

5.3 Lead Nurse for DSSA  The lead nurse will ensure that root cause analysis is undertaken by the specialties on all potential breaches to inform the decision making process.  A 48hr panel will be held with a member of the executive team to discuss the IMR/RCA and agree the classification prior to being confirmed and declared as a breach  Report any patients who have breached the Single Sex Accommodation policy to the commissioners as clinically justified or non-clinically justified. Any that are deemed not clinically justified are reported nationally via the Unify 2 by the Business Intelligence team.  Monitor breaches across the trust and ensure staff are aware of their responsibilities and provide education and support to teams.  Maintain high standards and compliance with single sex and ensure actions taken against lessons learnt are implemented to prevent any further mixed sex breaches occurring.  Provide monthly and annual updates on single sex breaches for the Quality Report.

6. PROCESS

6.1 Standards to be followed  All patients to receive an apology, explanation and written information within 24hrs of breach.  No patients to be nursed in mixed sex accommodation for more than 24 hours, each patient plus those affected will be classed as breaches. The rationale needs to be documented in patients clinical record  All toilets and bathrooms to be clearly labelled male/ female or disabled unless a single facility

6.2 Breach of this Policy and responsibilities of all staff  Patients who breach the 24hr policy must have a Safety Learning Event form raised and an IMR/RCA (attached) completed for investigation by the specialty Matron and forwarded ASAP to the Lead Nurse for DSSA. Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 6 of 50  Non-compliance with a Trust policy, procedure, guideline, PGD, protocol or patient information standard may result in disciplinary action.

6.3 Escalation If it is not possible to provide single sex accommodation this should be escalated as follows:  Discussion with Patient Flow Manager where appropriate (in hours).  Discuss with specialty Matron (in hours) and Duty Matron out of hours.  Discuss with Duty Hospital Manager (in and out of hours).  The Duty Executive must be informed  A Safety Learning Event and IMR/RCA form should be completed

6.4. In the overall best interests of the patient- i.e. with regard for the patients’ benefit or advantage

There are situations where it is clearly in the patients’ best interests to receive rapid or specialist treatment, and same sex accommodation is not the immediate priority. In these cases, privacy and dignity must be protected- e.g. by the enhanced staffing in critical care facilities and the flexibility to be able to provide privacy for specific treatments or personal care is offered i.e. Height and weight facilities. The patient should be provided with same sex accommodation immediately the acceptable justification ceases to apply.

6.5 Acceptable Justification i.e. not a breach

1) Safety: In the event of a life-threatening emergency, either on admission or due to a sudden deterioration in a patients’ condition or segregation would put the patient or others in danger of harm.

2) Acuity: Where a critically ill patient requires constant one to one nursing care e.g. HDU or ITU or where a nurse must be physically present in the room/ bay at all times (the nurse may have responsibility for more than one patients (e.g. level 2 care) This would be unacceptable if staff shortages or skill mix were the rationale

3) Specialist Care or Observation: Where a short period of close patient observation is needed e.g. immediately post anaesthetic recovery or where there is a high risk of adverse drug reactions.

4) Patient Preference On the joint admission of couples, family groups or young people 13-19 yrs., however in all cases individual’s privacy and dignity should be maintained, and verbal consent should be gained and documented.

6.6 Unacceptable Justifications i.e. Breach

 Placing a patient in mixed sex accommodation for the convenience of medical, nursing or from a desire to group patients in a clinical specialty.  Placing a patient in mixed sex accommodation because of a shortage of staff or poor skill mix  Placing a patient in mixed sex accommodation because of restrictions imposed by old or difficult estate  Placing a patient in mixed sex accommodation because of a shortage of beds  Placing a patient in mixed sex accommodation because of predictable fluctuations in activity or seasonal pressures  Placing a patient in mixed sex accommodation because of predictable non clinical incident e.g. ward closure  Placing or leaving a patient in mixed sex accommodation whilst waiting for assessment, treatment or a clinical decision  Placing a patient in mixed sex accommodation for regular but not constant observation

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 7 of 50 It is not acceptable to mix sexes purely on a basis of clinical specialism.

6.7. Reflecting Patient Choice  There are some instances when sharing accommodation with the opposite gender reflects personal choice and may therefore be justified. In all cases privacy and dignity should be assured. Group decisions should be reconsidered for each new admission to the group, as consent cannot be presumed. This personal choice should be documented within the patient’s notes.

6.8 Acceptable Justification i.e. not a breach  If an entire patient group has expressed an active preference e.g. renal dialysis (This preference should be made clear in their notes and clear signs displayed explaining rights to choose)  If individual patients have specifically asked to share and other patients are not adversely affected (e.g. children/young people who have expressed an active preference for sharing with people of their own age group, rather than gender)

6.9 Unacceptable Justifications i.e. breach  If a patient is asked to choose between accepting mixed sex accommodation, or going elsewhere.  If the patient is asked to prioritise same sex accommodation over another aspect of care (e.g. speed of admission, specialist staff etc.)  The routine mixing of young people without establishing preferences.  There should always be segregation unless the patients asked specifically to share  If the patient did not express a preference (it cannot be presumed that they will find sharing acceptable)

(Annex A DH Gateway 15024)

7. AREAS AFFECTED BY THIS POLICY

Breach Risk Definition

A Single Sex Accommodation breach is never acceptable and rarely justified in the following areas e.g. Red  General ward areas e.g. medicine, surgery, trauma and orthopaedics.  For vulnerable patients e.g. with dementia, a mental health issue or learning disability.  Temporary/winter wards.

A Single Sex Accommodation breach is occasionally acceptable/justified in the following areas e.g.  Children and young people – based on individual choice around age versus gender Amber segregation.  Clinical specialties which are located on one place and where it would be detrimental to the patient’s medical care for them not to be in the specialty (e.g. Head & Neck).  Day case units, endoscopy.

Usually justified/acceptable e.g.  Level 2 high dependency units. Green  Level 3 critical care units.  Recovery units – where patients are recovering from procedures for a short time.

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 8 of 50 7.1 General Inpatient wards There are no clinical justifications for mixing sexes within general wards and any breaches must be declared and the patient moved to a more appropriate place within 24hrs.

Common sense and discussion should also prevail about arrangements for adult carers of people with specialist communication needs.

7.2 MAU/ SAU/CAU/Observation areas Admission and assessment areas can be difficult to segregate but there are no clinical justifications for placing patients in mixed sex accommodation within these areas. Toilets and bathrooms should be single sex facilities. Breaches to segregation must be declared along with numbers of other patients affected by the breach. Patients in observation beds should be segregated and any breach to this must be declared. Not acceptable for organisational convenience or as a routine occurrence

7.3 Emergency Department /Paediatric Emergency Department Emergency cases to ED must be treated and cared for with respect to their individual privacy and dignity needs, single sex toilets and bathrooms must be available. Patients within the observation ward should be segregated and any breach to this must be declared.

7.4 Endoscopy and Day Case Suites Areas where patients are admitted and cared for on beds or trollies and are undressed must meet the DH guidance for single sex. Where practicable it is expected that organisational changes will be made to undertake single sex lists. In the absence of this, every effort will be made to segregate sexes by the use of cohorts, screens and process changes to allow for minimal opportunity for patients accidental exposure to the opposite sex. Not acceptable where dignity is likely to be compromised e.g. if bowel prep is needed and/or patients are required to undress. Toilet facilities should be allocated for single sex use, patients should be kept clothed as much as possible to reduce dignity issues.

If Endoscopy suites, Ambulatory, Day Case areas or the Discharge lounge are used for outlier patients as per the Trust escalation policy they must meet the requirements for inpatient wards to avoid mixed sex breaches and promote patient privacy and dignity. Local guidance is available on CDU (see Appendix 4) and RDU to avoid mixed sex breaches.

7. 5 Department of Critical Care and High Care Areas (RHCU, SHCU and Hyperacute beds on F4 for thrombolysis). The Level 2 and 3 patients admitted to these units will be cared for in a manner that is supportive of their individual privacy and dignity requirements. However the extensive clinical care and support is of paramount importance and therefore no guarantee can be given that the patients will occupy a single sex bay. This is an acceptable clinical breach.

In Level 2 and 3 facilities the clinical justification no longer applies once a decision has been made to transfer the patient to a ward area and cannot be moved - see Appendix 3 ITU Operational Guidance for Delivering Single Sex Accommodation. If level 1 patients are admitted to RHCU or SHCU these need to be segregated from the High Care patients and single sexed by use of cubicles or screens.

7.6 Recovery areas Following theatre or other procedures, the patient’s safe recovery is of utmost importance; hence the priority will be ensuring the observation and maintenance of their airway and quick appropriate interventions. All patients will be treated in a dignified way and their privacy will be safeguarded at all times by their allocated practitioner.

If patients remain in recovery until discharge or patients are outlied to this area as part of the Trust escalation plan then it is classed as an Unacceptable justification (i.e. a breach) area. Recovery Operational guidance for Delivering Single Sex Accommodation (Appendix 3) and Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 9 of 50 CHAT Outlier SOP: http://pht/Departments/DaySurgery/Standard%20Operating %20Procedures%20Documents%20SOPs/Forms/AllItems.aspx which provide guidance about how to avoid mixed sex breaches and promote patient privacy and dignity. These patients must be screened from the recovery patients.

7.7 Children and Adolescents’ wards/areas There are good reasons why children and young people are grouped together according to age rather than gender. What is important is taking into account their physical, psychological, clinical and social needs. The flexibility to be able to provide privacy for specific treatments or personal care is valuable i.e. height and weight facilities.

Common sense and discussion should also prevail about arrangements for parents and siblings to visit freely and to stay overnight, Staff should ask the child or young person if they have a preference for age or gender specific accommodation, ideally in conjunction with their family on each admission.

7.8 Day Units for Children and Young People While sleeping arrangements do not feature in day treatment areas, standards of privacy and dignity for patients still apply. The presumption for most patients should be that they do not have to be cared for in the same room with patients of the opposite sex; that they will be protected from unwanted exposure if they have to undress; and confidential conversations with staff cannot be overheard.

However, some patients who attend the same day area regularly (for example for dialysis) may build friendships, which transcend a preference for same-sex segregation. A balance should be struck, which may vary from one group to another.

8. DELIVERING SAME-SEX ACCOMMODATION FOR TRANS PEOPLE AND GENDER VARIANT CHILDREN

8.1 Trans-sexual Adults Transsexual people, that is, individuals who have proposed, commenced or completed reassignment of gender, are legally protected against discrimination (see The Gender Recognition Act 2004).

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.

General key points are that:

 Trans people should be accommodated according to their presentation: the way they dress, and the name and pronouns that they currently use.  This may not always accord with the physical sex appearance of the chest or genitalia;  It does not depend upon their having a gender recognition certificate (GRC) or legal name change;  It applies to toilet and bathing facilities (except, for instance, that pre-operative trans people should not share open shower facilities);  Views of family members may not accord with the trans person’s wishes, in which case, the trans person’s view takes priority.

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. This approach may only be varied under special Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 10 of 50 circumstances where, for instance, the treatment is sex-specific and necessitates a trans person being placed in an otherwise opposite gender ward e.g. when a trans man is having a hysterectomy in a 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 (see http://www.gires.org.uk/assets/trans- rights.pdf section 1.4, pp9, 10). Such departures should be proportionate to achieving a ‘legitimate aim’, for instance, a safe nursing environment.

In addition to these safeguards, where admission/triage staff 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 to the usual safeguards outlined in relation to all other patients, 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.

Appropriate dignity and modesty considerations must also be given to other patients in the ward through the appropriate use of screens and curtains.

8.2 Gender variant children and young people

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.

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. 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.

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.

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.

9. TRAINING REQUIREMENTS Through CSCs and Specialty groups i.e. Trust Adolescent Working Group Dept. Training days where applicable i.e. Paediatric Unit Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 11 of 50 Team Brief Handovers

10.REFERENCES AND ASSOCIATED DOCUMENTATION Update letter (CNO & Dep NHS CE 2010) available at: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicatio nsandstatistics/Lettersandcirculars/Professionalletters/Chiefnursingofficerletters/DH_121848

http://www.gires.org.uk/assets/trans-rights.pdf section 1.4, pp9, 10

Equality Act 2010: https://www.gov.uk/guidance/equality-act-2010-guidance

C and Y P Health Outcome Report (2103)

Links to other key Strategies & Policies  The policy is based on the revised Operating Framework for 2010-2011 expectation that NHS organisations will eliminate mixed sex accommodation, except where it is in the best interests of the patient, or reflects personal choice.  The Policy is supported by Chief Nursing Officer and Director General Finance, Performance and Operations Update (DH, 2009) on Privacy & Dignity, the RCN Defending Dignity Campaign, the Dignity in Care Campaign and the Good Practice Guidance.

11.EQUALITY IMPACT STATEMENT Portsmouth Hospitals NHS 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 policy has been assessed accordingly

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do. We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity Quality of care Working together Efficiency

This policy should be read and implemented with the Trust Values in mind at all times.

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 12 of 50 12.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

Minimum requirement to Lead Tool Frequency of Report Reporting arrangements Lead(s) for acting on be monitored of Compliance Recommendations

RCAs relating to non- CSC Single Sex Breach Root When a breach occurs 48 hr. Panel to be organized and CSC Management team Cause Analysis compliance Management chaired by executive Lead Nurse for DSSA and Head team Monthly & Annual Quality Report of Nursing for Children and Unify for any breaches Young People 0-19years Daily checks of escalation Director of Daily staffing sheets Daily Escalate as per DSSA flowchart to CSC Management team areas by Duty Matron and Nursing resolve any concerns. Duty Hospital Managers Hospital @Night Monthly & Annual Quality Report Lead Nurse for DSSA Inpatient survey results Head of Annual Inpatient Survey Annual Annual Quality Account Associate Director of Quality and Patient Governance and Quality Committee Governance. Experience Head of Patient Experience Lead Nurse for DSSA and Head of Nursing for Children and Young People 0-19years Patient feedback through Head of Complaints Annual Quality Account Associate Director of Quality and FFT, PALS and complaints Patient FFT Results Governance and Quality Committee Governance. Experience Head of Patient Experience Lead Nurse for DSSA and Head of Nursing for Children and Young People 0-19years

This document will be monitored to ensure it is effective and to assurance compliance.

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 13 of 50 Appendix 1 - WRITTEN APOLOGY TO BE GIVEN TO THE PATIENT

Dear Patient,

We are sorry that it has not been possible to admit you into single sex accommodation, the mixing of sexes within bays is not a situation that we consider to be acceptable.

Please can we offer our sincere apologies for your current position, and reassure you that every effort will be made to rectify your situation by moving you to an appropriate single sex bay within 24 hours, if not sooner.

However, if you feel your current accommodation is unacceptable in the short term and you wish to talk to someone please let the ward know, and we will try to get a senior member of staff along as soon as possible.

Please accept our sincere apologies for this situation once again.

Yours Sincerely

The Hospital Management Team

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 14 of 50 Appendix 2: SINGLE SEX BREACH ROOT CAUSE ANALYSIS

CSC/Speciality Date of Initial Review Panel Outcome Investigating Officer/Report Author Date of Report Date of Final Panel Outcome

Initial management Report All areas to be completed prior to Review Panel

Event date and Date and length Incident Number: time of occurrence

State of Hospital Green/ Amber/Red/Black Number of medically fit patients awaiting discharge Date occurrence Ward and CSC reported to Lead Nurse Duration: Supplementary Address Male/ Female Information Name NHS Number Breach Patient Name Address Male/ Female Details NHS Number Name Address Male/ Female NHS Number Name Address Male/ Female NHS Number Affected Patient Name Address Male/ Female Details NHS Number Name Address Male/ Female NHS Number

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 15 of 50 Name Address Male/ Female NHS Number Name Address Male/ Female NHS Number Admission Method ( where appropriate): Emergency Elective

Effect on Patients

Was this Safety occurrence clinically Acuity justified?- please refer to policy Specialist Care or observation before completing Patient preference

Actions Immediate Interventions undertaken to avoid breach and or/resolve the breach

Escalated to Matron/ Head of Nursing- name

Escalated to Duty Hospital Manager- name

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 16 of 50 Escalated to Duty Director- name

Written apologies issued- by whom

Good Practice

Care (Care Delivery: relates to direct provision of care arising during the process of care – usually actions or omissions by members of staff. E.g. (1) care which Delivery/Service deviated beyond safe practice (2) the deviation had at least a potential direct or indirect effect on the adverse outcome for the patient, member of staff or ‘general public’. Service Delivery: failures identified, which are associated with the way a service is delivered and the decisions, procedures and systems that are part of Delivery Problem the whole process of service delivery 1

2

3

Root Cause(s) (The prime reason(s) why the incident occurred; fundamental factors, removal of which will either prevent, or reduce, the chances of a similar type of incident occurring in similar circumstances in the future. Root causes should be meaningful – not sound bites such as communication failure – and there should be a clear link, by analysis, between root CAUSE and EFFECT on the patient) 1

2

3

Lessons Learnt

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 17 of 50 Conclusion of panel Justified due to-

Not justified and declared to Commissioners-

Panel Membership Name Job Title

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 18 of 50 Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 19 of 50 Appendix 3: OPERATIONAL GUIDANCE CHAT CSC

Delivering Same Sex Accommodation (DSSA) - Operational Guidance Critical Care, HSDU, Anaesthetics and Theatres CSC (Re-draft Feb 2017)

Introduction

This guideline is to be used in conjunction with the Trust Policy “Delivering Single Sex Accommodation (DSSA) Policy” [DSSA - Trust Policy] and the CSC Escalation Process [see page 4]. The general overview of areas where there is a degree of flexibility with the provision of same-sex areas are:-

Breach Definition Risk Red A Single Sex Accommodation breach is never acceptable and rarely justified in the following areas e.g.  General ward areas e.g. medicine, surgery, trauma and orthopaedics.  For vulnerable patients e.g. with dementia, a mental health issue or learning disability.  Temporary/winter wards.  In level 2 and 3 facilities where the clinical justification no longer applies once the decision has been made to transfer the patient to a ward area and cannot be moved Amber A Single Sex Accommodation breach is occasionally acceptable/justified in the following areas e.g.  Children and young people – based on individual choice around age versus gender segregation.  Clinical specialties which are located on one place and where it would be detrimental to the patient’s medical care for them not to be in the specialty (e.g. Head & Neck).  Day case units, endoscopy. Green Usually justified/acceptable e.g.  Level 2 high dependency units.  Level 3 critical care units.  Recovery units – where patients are recovering from procedures for a short time.

The Critical Care, HSDU, Dept of Anaesthesia and Theatres (CHAT) CSC have areas which fall within all three breach risk (i.e. never acceptable [Theatre Admissions], occasionally justified [Day Surgery] and usually justifiable [Recovery and ITU]). However as there are some privacy and dignity considerations to be made, either through patient choice or bed pressures, the following guidance is to be used. Theatre Admissions (TSA) and Day Surgery Unit (DSU) admissions – the basis of single-sexing is that services do not expect a patient to have compromises made to their privacy and dignity. Therefore for patient admissions to TSA and DSU it is expected that once Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 20 of 50 a patient changes out of their normal clothes that they are asked to sit within the single-sexed patient wait areas. However, a patient who is changed in to a theatre gown may decide that they would like to remain with a family/carer and choose to sit back out in the normal waiting area; it is wholly acceptable for a patient to make a choice that their privacy and dignity is not compromised by this and thus their wishes should be accommodated (as long as this is clinically safe). For patients who have a strong desire to remain with a relative (for example, adolescents/frail/anxiety disorders, etc.), but they do feel their privacy and dignity would be compromised by sitting in a normal wait area, escalation should be made to a more senior nurse/manager to establish how this could also be accommodated, i.e. by using a consulting room if available.

CHAT CSC Delivering Same Sex Accommodation (DSSA) Breach Matrix

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 21 of 50 Actions and Confirmation of Breach Criteria Breach Rec Risk Day Surgery Unit and Theatre ITU ove Admissions ry Red HIGH BREACH RISK Patient breaches when an individual patient is fully Patient When Day Surgery Unit 2nd stage is being utilised ready and referred for ward care over 24 hours and breaches for bedded inpatients if not patients of the same cannot/or is not already accommodated in a single when sex. room/cohorted bed space. ready for discharge from Recovery but this has been delayed and the patient is requiring to take fluid and diet and mobilising to use a shared bathroom facilities (if walking visibly across the path of a patient of the opposite sex).

If recovery is used for

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 22 of 50  Breac hes will not be report ed unless they are not clinical ly justifie d (e.g. for capaci ty).

 In Level 2 and 3 units the clinical justific ation no longer applie s once a decisi on has been made to transfe r the

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 23 of 50 patient to level 1 care (if the move is undert aken out with the normal and agree d practic e with the CCG). The clinical justific ation will still apply if the medic al consul tant has advise d that it is not in the

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 24 of 50 patient s best interes ts to move them within the unit to preven t a breach .

 Escala te to: In Hours to the senior manag ement teams (Band 7, Matro n, Operat ional Manag er, Clinica l Direct or CS C Manag

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 25 of 50 ement Team out of Hours (OOH) – Duty Hospit al Manag er (DHM) and/or Hospit al at Night Team (H@N ).

 Impen ding Single Sex Accom modati on beach es will be discus sed at Hospit al Operat ions Meetin g if the plans

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 26 of 50 by the Senior Manag ement Team may be compr omise d due to hospit al pressu res (this is particu larly import ant for the Out of Hours period s).

 Clinica lly and non- clinical ly justifie d sleepi ng and facilitie s

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 27 of 50 breach es will always be report ed via an amber Safety Learni ng event on Datix.

 Notify the Trust DSSA lead.

 The CSC should arrang e the panel ideally within 48hrs as per

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 28 of 50 the Trust policy

 If a breach has occurr ed follow the Trust Policy for notifyi ng the patient and followi ng-up with a letter of apolog y.

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 29 of 50 surgical outliers overnight as per the Trust escalation policy refer to the CHAT Outlier policy http://pht/ Departme nts/DaySu rgery/Stan dard %20Opera ting %20Proce dures %20Docu ments %20SOPs /Forms/AllI tems.aspx which provides more detailed informatio n about how to segregate recovery to comply with single sex accommo

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 30 of 50 dation guidelines which includes floor plans (see page 4 for an example).

ACTIONS TO BE TAKEN TO AVOID PRIVACY AND DIGNITY BREACH Keep patient accommodated within a single room/  C N/A – if this was being used and patients were cohorted bed space if appropriate (and if other oh mixed it would constitute a breach. patients care is not compromised as a result). ort pa tie nt s w ait in g di sc ha rg e

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 31 of 50 if cli ni ca lly sa fe an d po ssi bl e (if no t be in g us ed co ns id er ba ys 15 /1 6, 22 /2 3 or

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 32 of 50 pa ed iat ric re co ve ry) ;

 En su re m al e/f e m al e pa tie nt s ar e no t pl ac ed op po sit

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 33 of 50 e ea ch ot he r (i. e. in cl os e pr ox im ity an d in dir ec t vi e w) as far as is pr ac tic ab ly

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 34 of 50 an d sa fe.

 Uti lis ati on of sc re en s an d cu rta in s as pe r C D U “M ix ed Se x Ac co m

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 35 of 50 m od ati on br ea ch av oi da nc e” gu id an ce m ap s (s ee pa ge 4).

Amber MEDIUM BREACH RISK – CLINICALLY APPROPRIATE Patients ready for ward care but within 24 hours of Patients Consideration being made to open Day Surgery referral. Extra attention will be given to ensuring meet Unit for bedded inpatients. Segregate long stay their privacy and dignity by use of curtains, cohorted discharge patient’s male/female within the area. bed space etc., criteria and are more alert but not at mobilisatio

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 36 of 50 n stage, therefore privacy and dignity met by cohorting patients waiting discharge and using screens and curtains.

Green LOW BREACH RISK – CLINICALLY APPROPRIATE All patients admitted to Critical Care whatever their Patients Patients not breaching but maintaining privacy and level of care will have consideration re: Single Sex not dignity levels. Accommodation issues. Their privacy and dignity breaching will be maintained at all times. as actions Male/Female patients are not placed opposite taken to each other (i.e. in close proximity and in direct maintain view) as far as is practicably safe. Utilisation of privacy screens and curtains. and dignity.

Male/Fem ale patients are not placed opposite each other (i.e. in close proximity and in direct

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 37 of 50 view) to avoid accidental exposure of the opposite sex.

Appropriat e screens are in place.

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 38 of 50 Theatre Recovery - Patient Flow Escalation Process

Background

Delayed moves from Theatre Recovery may compromise patient privacy and dignity and patient flows through theatres. Once a patient is deemed fit for discharge back to a ward environment this move should occur within 30 -60 minutes, otherwise this could risk triggering a single-sex breach as the patient is no longer deemed to have a clinical justification for being with a mixed-sexed environment. This normally occurs promptly for current inpatients but is more of a challenge for patients coming in via the Theatre Admissions pathway.

As a result it has been necessary to develop an escalation process for notification of delays:-

In-Hours - when the Operational, Nursing and General Management teams are on site (0800-1700hrs - weekdays* excluding BH’s).

Out of Hours - (nights, weekends, BHs) via escalation to the Duty Hospital Manager (bleep 1118) > 45 mins.

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 39 of 50 Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 40 of 50 Appendix 4: OPERATIONAL GUIDANCE FOR CARDIAC DAY UNIT (CDU)

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 41 of 50 Delivering Single Sex Accommodation (DSSA) – Operational Guidance for Cardiac Day Unit (CDU)

Introduction

This guideline is to be used in conjunction with the Trust Policy “Delivering Single Sex Accommodation (DSSA) Policy” [DSSA - Trust Policy]. The general overview of areas where there is a degree of flexibility with the provision of same-sex areas are:-

Breach Risk Definition Red (Never) A Single Sex Accommodation breach is never acceptable and rarely justified in the following areas e.g.  General ward areas e.g. medicine, surgery, trauma and orthopaedics.  For vulnerable patients e.g. with dementia, a mental health issue or learning disability.  Temporary/winter/escalation wards. Amber A Single Sex Accommodation breach is occasionally acceptable/justified in the following areas e.g. (Sometimes)  Children and young people – based on individual choice around age versus gender segregation.  Clinical specialties which are located on one place and where it would be detrimental to the patient’s medical care for them not to be in the specialty (e.g. Head & Neck).  Day case units, endoscopy due to clinical urgency Green Usually justified/acceptable e.g. (Almost  Elective admissions where 7 or less single gender admissions booked always)  Level 2 high dependency units.  Level 3 critical care units.  Recovery units attached to theatres/procedure rooms where patients are recovering from procedures for a short time.

Cardiac Day Unit elective admissions – the basis of single-sexing is that services do not expect a patient to have compromises made to their privacy and dignity.

Therefore for patient admissions to CDU it is expected that once an elective patient changes out of their normal clothes that they are asked to confine their movements within the single-sexed patient areas as defined by the privacy screens. However, a patient who is changed into a cath lab lounge suit may decide that they would like to remain with a family/carer and choose to sit back out in the normal waiting area; it is wholly acceptable for a patient to make a choice that their privacy and dignity is not compromised by this and thus their wishes should be accommodated (as long as this is clinically safe). For patients who have a strong desire to remain with a relative (for example,

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 42 of 50 adolescents/frail/anxiety disorders, etc.), but they do feel their privacy and dignity would be compromised by sitting in a normal wait area or they are currently unable to mobilise; escalation should be made to a more senior nurse/manager to establish how this could also be accommodated, i.e. by utilising privacy screens as per CDU “Mixed Sex Accommodation breach avoidance” guidance maps (see example on page 4). This can be mitigated by ensuring all patients are wearing a cath lab lounge suit.

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 43 of 50 Actions and Confirmation of Breach Criteria Breach Comments Risk Elective capacity only Unfunded escalation capacity

Red HIGH BREACH RISK Patient breaches occur when more than 7 Potential breaches will occur when CDU is being An Acceptable Justification i.e. not a breach patients of one gender are admitted and are utilised for bedded inpatients if patients are not of can be applied (in line with the Trust policy mobilising post procedure as part of their the same sex and screens are not in use. The risk sections 6.4, 6.5.1, 6.5.2 and 6.5.3) for the recovery or to use bathroom facilities (if walking of accidental exposure to the opposite sex following reasons: visibly across the path of a patient of the increases when the number of inpatients is over 7. opposite sex). 1. Admission of Primary PCI (life- threatening emergency admission) patient to CDU if a CCU bed or Cath Lab is unavailable.

2. Immediate and short-term recovery of a Primary PCI patient where a CCU bed is unavailable.

 Same sex accommodation should be provided immediately the acceptable justification ceases to apply i.e. CCU bed ACTIONS TO BE TAKEN TO AVOID PRIVACY AND DIGNITY BREACH or Cath Lab available. Privacy and dignity  Single sex lists where practicable  Medical outliers will be single sex and limited must be protected- e.g. use of mobile to 7. privacy screens where safe and  If single sex lists not practicable use privacy appropriate. screens as per CDU “Mixed Sex  Elective lists to be single sex and the same Accommodation breach avoidance” sex as the outliers where practicable  In all instances, escalate to: In Hours the guidance maps (see page 4). . CDU management teams (Band 7, Matron,  If mixed sex lists are unavoidable due to Operational Manager, Clinical Director  Male/Female patients are not placed waiting list constraints the use of privacy CSC Management Team Out of Hours opposite each other (i.e. in close proximity screens must be used to segregate sleeping (OOH) – Duty Hospital Manager (DHM) and in direct view) as far as is practicably and bathroom facilities (as per CDU “Mixed and/or Hospital at Night Team (H@N). and safe. Sex Accommodation breach avoidance” guidance maps (see page 4).  Escalate any impending Single Sex  Use Cath Lab lounge suits for all patients – Accommodation breaches at the Hospital Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 44 of 50 this will ensure privacy and dignity whilst the  Use Cath Lab lounge suits for all elective patient is safely prepared for/recovering patients if they are of the opposite sex to from their procedure other patients on the list and the inpatients

Amber MEDIUM BREACH RISK – CLINICALLY APPROPRIATE Patients meet discharge criteria and are more Consideration being made to open CDU for alert but not at mobilisation stage, therefore bedded inpatients. privacy and dignity met by cohorting patients Segregate long stay patients from elective waiting discharge and using screens and male/female patients within the area. curtains.

ACTIONS TO BE TAKEN TO AVOID PRIVACY AND DIGNITY BREACH  Ensure male/female patients are not placed opposite each other (i.e. in close proximity and in direct view) as far as is practicably and safe.

 Utilisation of screens and curtains as per CDU “Mixed Sex Accommodation breach avoidance” guidance maps (see page 4).

 Use Cath Lab lounge suits for all patients to ensure patient privacy and dignity whilst the patient is safely prepared for/recovering from their procedure

Green LOW BREACH RISK – CLINICALLY APPROPRIATE Patients not breaching if 7 or less of each Patients not breaching if single sex only gender admitted but actions taken to maintain throughout CDU but maintaining privacy and privacy and dignity. dignity levels.

Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 45 of 50 Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 46 of 50 Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 47 of 50 Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 48 of 50 EQUALITY IMPACT SCREENING TOOL To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments.

Stage 1 - Screening

Title of Procedural Document: Delivering Single Sex (DSSA) Policy

Date of assessment 27.10.2017 Responsible Corporate Department Name of person Liz Hall Job Title Lead Nurse DSSA and completing Head of Nursing for CHAT assessment Does the policy/function affect one group less or more favourably than another on the basis of : Yes/No Comments

 Age No  Disability No Learning disability; physical disability; sensory impairment and/or mental health problems e.g. dementia  Ethnic Origin (including gypsies and travellers) No  Gender reassignment No  Pregnancy or Maternity No  Race No  Sex No  Religion and Belief No  Sexual Orientation No If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below www.legislation.gov.uk/ukpga/2010/15/contents

Stage 2 – Full Impact Assessment Delivering Single Sex Accommodation Policy (DSSA) Version: 8 Issue Date: 11 December 2017 Review Date: 10 December 2020 (unless requirements change) Page 49 of 50 What is the impact Level of Mitigating Actions Responsible Impact (what needs to be done to minimise / Officer remove the impact)

Monitoring of Actions The monitoring of actions to mitigate any impact will be undertaken at the appropriate level

Specialty Procedural Document: Specialty Governance Committee Clinical Service Centre Procedural Document: Clinical Service Centre Governance Committee Corporate Procedural Document: Relevant Corporate Committee

All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee

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