Head of Patient Experience Version 2

Trust Privacy and Dignity Policy (incorporating single sex accommodation) Author(s) Margaret Howat Head of Patient Experience Version 2 Version Date January 2017 Implementation/approval Date January 2017 Review Date January 2020 Review Body Policy Reference Number Patient Experience and Engagement Committee 1

Contents Summary 3 Introduction 3 Scope 4 Roles and responsibilities 4 Respecting Privacy and Dignity 5 Delivering Single Sex Accommodation 10 Training and Awareness 15 Review 15 Reporting & monitoring 16 o o Delivering Single Sex Accommodation Privacy & dignity 16 16 References 16 Appendix 1: SSA Breach Exception Report 17 Equalities impact assessment 18 Policy Submission 20 2

1 Summary 1.1. Homerton University Hospital NHS Foundation Trust (the Trust) is committed to providing high quality care to patients at all times. This includes respecting individuals right to privacy and dignity at all times and creating an environment in which human rights are respected. 1.2. This policy details how the Trust will meet the privacy and dignity of patients and their carers and includes delivering same sex accommodation (DSSA) requirements for hospital based care. 1.3. This policy is designed to guide managers and employees on the Trust standards with regard to privacy and dignity. 1.4. The policy is not exhaustive in defining acceptable and unacceptable standards and staff should be aware of risk assessment issues in adhering to the principles underpinning the policy such as DSSA. 1.5. This policy should be read in conjunction with the Trust Chaperone Policy (2016) 2 Introduction 2.1. The Human Rights Act (1998) ensures non-discriminatory treatment and provides protection of an individual's dignity and privacy. 2.2. All patients, visitors, carers should be treated with privacy, dignity and respect at all times and be afforded personal privacy as much as is reasonably practicable to carry out safe care. 2.3. Staff have a responsibility with regards to privacy and dignity to promote appropriate staff attitudes. 2.4. A fundamental aspect of human rights is an individual s right to humane and dignified treatment. Human rights are based on core values including: fairness respect equality dignity autonomy 2.5. Privacy refers to freedom from intrusion and relates to all information and practice that is personal or sensitive in nature to an individual. 2.6. Dignity is to treat someone as being worthy of respect in a way that is respectful of them as valued individuals. 2.7. Respect is being polite thoughtful and caring, ensuring privacy and ensuring good communication. 2.8. In addition to these definitions, the Department of Health Dignity in Care Campaign and related standards suggest that dignity issues overlap with 2.9. other areas: 3

Modesty: not being embarrassed Autonomy: involvement in decisions Respect: courteous regard for people s feelings 2.10. This policy also supports the City & Hackney Older People s Dignity Code 2010 which has been developed by older people across the two Boroughs and endorsed in 2013 by the City & Hackney Clinical Commissioning Group. The key principles are incorporated throughout the policy and posters of the code are available in clinical areas. 2.11. Particular care is required for children, young people and vulnerable people of any age who may have been previously subject to abuse including sexual abuse. 2.12. Staff should be aware that the intimate nature of many health care interventions, if not practiced in a sensitive and respectful manner, can in some circumstances lead to misinterpretation and allegations of abuse. 3 Scope 3.1. This policy applies to all those working in the Trust, in whatever capacity. Failure to follow the requirements of the policy may result in investigation and management action being taken as considered appropriate. This may include formal action in line with the Trust's disciplinary or capability procedures for Trust employees; and other action in relation to other workers, which may result in the termination of an assignment, placement, secondment or honorary arrangement. 4 Roles and Responsibilities 4.1. Chief Executive has overall responsibility for the policy 4.2. Chief Nurse and Director of Governance is responsible for implementing the policy on a day-by-day basis 4.3. Responsibility for protecting privacy and dignity does not lie with one individual or group but with staff at every level within the organisation. 4.4. Individual staff will: 4.4.1. Comply with professional codes of practice and governing bodies 4.4.2. Comply with the Trust four core values 4.4.3. Understand and practice within the Trust s policy framework 4.4.4. Uphold the duty of care and practice within the legislative framework 4.4.5. Be able to challenge poor practice without fear of reproach 4.5. Managers in addition to the above will: 4.5.1. Ensure that individuals within their teams understand their roles and responsibilities with regard to privacy and dignity and DSSA 4.5.2. Understand and implement specific privacy and dignity activity related to their service 4

4.5.3. Ensure that staff have the necessary resources and skills to promote and deliver services which respect privacy and dignity 4.5.4. Monitor team activity with regard to privacy and dignity 4.5.5. Lead, promote and champion the privacy and dignity agenda 4.5.6. Ensure that measurable standards are met 4.5.7. Support the Trust in gathering timely feedback from service users, their relatives and carers regarding privacy and dignity, and acting on information received to continually improve the care experiences of those who use our services 4.6. The Trust Board will: 4.6.1. Ensure that mechanisms are in place to provide the Board of Directors with regular information on the views of staff, service users, their relatives and carers 4.6.2. Receive regular reports on the status of the Trust in maintaining same sex accommodation in line with DSSA 4.6.3. Receive information from complaints and incidents which are related to privacy and dignity; this would include abuse and sexual safety issues 4.6.4. Consider the elimination of mixed sex accommodation in any refurbishment or new build capital development schemes and also ensure that space for private discussions is considered 4.6.5. Support training initiatives to promote the protection of privacy and dignity 4.7. Clinical site managers, lead nurses / matrons and operational leads will: 4.7.1. Be responsible for bed reports which take place four times a day seven days per week to indicate bed capacity 4.7.2. Manage their bed base and patient waiting areas (for example within wards and theatre admission / recovery areas) to ensure patients are cared for in single sex accommodation and that gender specific bathrooms are clearly identified and accessible. 4.8. The information team will: 4.8.1. Maintain DSSA breach reports including patient level data for reporting to executive team and commissioners. 4.9. The senior manager on call will: 4.9.1. Be responsible for reviewing real time bed demand and capacity during the on-call period and be accountable for authorising any breach of DSSA regulations. 5 Respecting Privacy and Dignity 5.1. The Dignity Challenge 5.1.1. The Dignity in Care campaign is promoted by the Department of Health requires staff to adopt the Dignity Challenge. The 10 core principles in the Dignity Challenge (2007) lay out the national expectations of what constitutes a service that respects dignity; the things that matter most to 5

people. In order to provide high quality services that respect people s dignity staff will: 1 Have a zero tolerance to all forms of abuse and be alert to safeguarding issues 2 Support people with the same respect they would want for themselves or a member of their family 3 Treat each person as an individual by offering a personalised service 4 Enable people to maintain the maximum possible level of independence choice and control 5 Listen and support people to express their needs and wants 6 Respect people s right to privacy 7 Ensure people feel able to complain without fear of retribution 8 Engage with family members and carers as care partners 9 Assist people to maintain confidence and a positive contribution 10 Act to alleviate people s loneliness and isolation 5.1.2. Dignity in healthcare for people with learning disabilities by the Royal College of Nurses (2010) provides guidance to improve dignity in healthcare for people with learning disabilities 5.1.3. Dignity and respect is at the heart of good quality and safe person centered care. All staff have a responsibility to ensure that people are treated with dignity and respect, especially vulnerable patients, and need to reflect the following privacy, dignity and modesty principles in their care. Patients have a right to: be treated as individuals at all times be listened to and their views taken into account at all times be treated courteously at all times be treated with dignity at all times to have their modesty protected at all times to have their cultural and religious needs considered in relation to privacy and modesty to remain autonomous and independent wherever possible to know who is responsible for the care they are receiving at that time have private discussions about their care and treatment when required 5.1.4. Staff need to refer to the Safeguarding Adult, Mental Capacity Act & Deprivation of Liberty Safeguards Policies and Safeguarding Children Policy when dealing with vulnerable adults and children, and seek further advice where there are concerns regarding a patient s capacity to consent to care or treatment or where they are unable to communicate their needs and have no family member or carer acting on their behalf. 6

5.2. Communication and Confidentiality 5.2.1. Appropriate communication with patients, families and carers is a key factor in promoting patient involvement and engagement with their care and by extension maintaining respect and dignity. 5.2.2. Patients have the right to expect that information is shared only to enable appropriate clinical care. 5.2.3. Staff should introduce themselves on initial contact with patients, relatives and carers including phone conversations and state their name and role. 5.2.4. Patients should be asked how they wish to be addressed and lapses into over-familiarity must be avoided. This must be recorded in the patient record and communicated to the team. Staff must not assume it is acceptable to use a patient s given name and must only do so with the patient s agreement. Informal terms or use of colloquial titles such as dear must not be used unless this is acceptable to and agreed by the patient first. 5.2.5. Staff must wear visible identification at all times. 5.2.6. All staff must knock before entering a patient s room in their home or a community setting, a hospital side room or ask for permission if bedside curtains are closed and wait for a reply before entering the bed space. 5.2.7. Patient s/relative s /carer s requests for assistance must be dealt with promptly. Where there is an unavoidable delay an apology and explanation will be given. 5.2.8. Staff should be aware of their body language and how this may be interpreted, for example standing with arms folded and avoiding eye contact when talking to a patient giving an impression that the interaction is impersonal and perhaps intimidating. Consideration should be given how body language can be perceived by different cultures. 5.2.9. When caring for, or in the presence of the patient, staff must not have personal conversations with colleagues that exclude the patient; for example talking about the rest of the day s workload while providing care to the patient 5.2.10. Consultations, treatment or discussions between clinical staff and patients/relatives /carers will not be interrupted except in an emergency. 5.2.11. Consideration must be given to providing a private space for confidential or sensitive discussions or to sit quietly; for example following bad news. Staff can access ward offices, meeting rooms and The Sanctuary for such purposes. 7

5.2.12. Language and behaviours should be inclusive and understandable; the face to face advocacy service, which includes sensory impairment, and phone interpreting services should be used as appropriate. 5.2.13. Patients with communication impairments such as visual, hearing or a learning disability should be provided with appropriate communication aids and support. 5.2.14. Patients whose knowledge and understanding may be limited, including their diagnosis, must have their care and treatment explained to them in a manner that they are able to understand and does not demean them 5.2.15. Patients should have the opportunity to have a relative, carer, parent or significant other present. This is particularly important if personal or distressing information is to be discussed. 5.2.16. Please refer to the Mental Capacity Act (2005) & Deprivation of Liberty Safeguards Policy (2017) for further guidance when caring for patients who do not have the mental capacity to make decisions about their care or treatment by virtue of their mental illness. 5.2.17. Staff must check that a patient s relative or carer has understood the information given and repeat, explain in a different way or ask for suitable advice to aid understanding. 5.2.18. Patient s consent should be obtained before disclosing information to family, friends or carers. If appropriate the patient will be asked on admission to nominate one key person who will be responsible for liaising directly with nursing and medical staff and record that name in the patient record. 5.2.19. Patients, relatives and carers should be asked whether they have any objection to healthcare professionals not directly in their care, for example, medical students being present at ward rounds, outpatient consultations. Time for consideration so they have the opportunity to decline must be given. 5.2.20. Staff should be aware of and alert to anyone who may overhear staff conversations, for example when handing over at the bedside or on the telephone. 5.2.21. In sharing information staff should be aware that other patients or visitors may be in earshot and modify their voice accordingly when discussing patient information, this is also important in the patient s own home. At night special care must be taken when ward noise levels are low. 5.2.22. Staff should keep in mind that curtains do not provide a sound barrier and conversations may be overheard particularly when a patient is hard of hearing. 5.2.23. It is not acceptable to discuss clinical information in public areas even if the patient s name is not used. 8

5.2.24. Personal information at the bedside should only display the minimum for safe care. 5.2.25. White boards containing patient names are necessary to help hospital staff locate patients and can reduce the risk of misidentification. In certain circumstances, for example where there are safeguarding issues, patient names should not be displayed. 5.2.26. Staff should make sure computer screens cannot be viewed by anyone other than those who have a clinical need to see the information and log out of computers before leaving them unattended. 5.2.27. All written patient information, for example, handover sheets and medical data which contains confidential details must be kept securely, not left in public areas and must be disposed of correctly in the confidential waste. 5.2.28. Staff should ensure that in all areas of the Trust mobile phones are not used in a manner that breaches the privacy of other patients and visitors, for example taking unauthorised photographs. 5.3. Privacy and Dignity 5.3.1. In providing care staff should actively promote privacy and dignity and safeguard patient modesty. 5.3.2. Patients individual preferences for night and day wear will be taken into consideration. Staff should meet cultural requirements for dress, undress and hygiene as reasonably requested by the patient. If their clinical condition and treatment allows patients should be encouraged to wear their own night and day clothes but must be made aware of storage limitations and the Property Policy. 5.3.3. Consideration should be given to the appropriateness of hospital gowns in preserving modesty when carrying out functional activities off the ward for example: to practice stair climbing, or for an assessment in the occupational therapy kitchen. Patients should be encouraged to wear their own day clothes. 5.3.4. Patients should not be asked to remove more clothing than is absolutely necessary. Patients should have the opportunity to re-dress following an examination before continuing with a consultation. 5.3.5. Gowns and drapes used in Theaters and Radiology should preserve the dignity of patients. Extra-large gowns should be used as and when required. 5.3.6. Patients should be asked before care is given whether they give permission to be washed or examined by a person of the opposite sex. Patient s wishes should be respected whenever possible and safe care allows. 9

5.3.7. Where required, or requested by the patient, a chaperone should be provided to patients and they should be given a choice as to who is present during examinations and treatment. 5.3.8. Patients must be given time to eat and drink without being rushed and assistance given as required in line with the protected mealtime policies. 5.3.9. Potentially embarrassing medical aids must be covered or affixed to minimise embarrassment at all times for example catheter bags. 5.3.10. When patients have to use a commode at their bed area staff should provide as much privacy as is possible. Commodes and bedpans should be removed as quickly and discreetly as possible. Patients should be assisted to the toilet or bathroom wherever the care plan allows 5.3.11. Special attention to patient comfort and modesty should be maintained when the patient is being transferred from one area of the hospital to another, for an Occupational Therapy home assessment, to a community setting or other hospital. Where it is not possible, or is inappropriate for example due to being medically unwell, for patients to wear their own clothes, staff should ensure patients are suitably covered by clothing or blankets during the transfer. 5.3.12. All staff are responsible to ensure doors are fully closed and bedside curtains or screens pulled together with no gaps in all areas where patients are required to undress, including outpatient settings. 5.4. Equality and Diversity 5.4.1. Staff should act in accordance with the Equality Act (2010) and the Trust Equality Objectives 5.4.2. No person is treated more or less favorably on the grounds of their race, ethnic group, religion/belief, disability, age, gender, sexual orientation 5.4.3. Staff will recognise and respond sensitively to individual preference, acknowledging and respecting people s expressed belief and acting according to their preferences and choices, values and beliefs about health and healthcare whenever and wherever possible 5.4.4. Staff will identify and take action when other s behaviours undermines equality and diversity. 6 Delivering Single Sex Accommodation 6.1. The Department of Health has issued standards on achieving same sex accommodation. This is provided in the following ways at the Trust: Same sex wards at the time of writing this policy - Priestley and Templar female wards 10

The Observational Medicine Unit (OMU) within Emergency Department (ED) have separate male and female bed areas and separate toilets. Patient in ED only change into gowns once in the cubicles Single rooms with adjacent or en-suite bathroom facilities some side rooms within wards Same sex accommodation within mixed wards (i.e. bays or rooms which accommodate either men or women but not both), with designated same sex bathroom facilities within or adjacent to the bay or room Sleeping accommodation includes areas where patients are admitted and cared for on beds or trolleys, even where they do not stay overnight. It therefore includes: Edith Cavell Lamb Lloyd Acute Care Unit Cardiology Graham Regional Neurological Rehabilitation Unit Elderly Care Unit Day Stay Unit Thomas Audley Starlight Maternity Surgical Centre Endoscopy unit Step down Observation unit A&E Intensive Care Unit (ICU) is a mixed nightingale ward and patients will as far as is possible be cared for with male patients grouped together and female patients grouped together to deliver care. This is dependent upon the clinical requirements and risk within the unit and the decision is made by the senior nurse on shift 6.1.1. Recovery is a mixed nightingale ward and patients will as far as is possible be cared for with males and females grouped together. This is dependent upon the clinical requirements and risk within the unit and the decision is made by the senior nurse on shift. 6.1.2. In Endoscopy each pod has a curtain which is kept closed on each individual pod. The exceptions are post procedure bronchoscopy patients, where the curtains are left open (but patients are fully clothed) due to safety issues. 6.1.3. Sleeping accommodation does not include areas where patients have not been admitted, such as accident and emergency cubicles and the medical day unit 6.1.4. Ward accommodation is arranged to ensure that there is physical segregation of sleeping bays and rooms for men and women at all times 6.1.5. There are sliding screens to isolate bays on many of the wards 6.1.6. Particular consideration should be given to transgender patients. See section 6.3 11

6.1.7. Bathroom facilities: Patients will not have to share bathroom facilities with people of the opposite sex and will not have to pass through sleeping areas used by the opposite sex in order to reach their own. Bathrooms have interchangeable signs to enable allocation of bathroom according to the gender of the nearest bay. Some bathrooms will have unisex toilet signs. For example the toilets in the ED waiting areas are single cubicles and not gender specific. Dementia friendly pictures are used to identify facilities. In some areas such as RNRU specialised bathroom equipment is installed and facilities will be used by all patients. It is the responsibility of the nurse in charge of the shift to ensure that bathroom signs are changed following bay moves and rechecked at least once per shift. Bathrooms are lockable. 6.2. Day stay, endoscopy and outpatients services. 6.2.1. Although sleeping accommodation is not an issue within these departments patient s privacy and dignity should be protected at all times; particularly: Where modesty may be compromised such as wearing a hospital gown or where parts of the body other than the extremities are exposed greater segregation will be provided. This includes separate male and female waiting areas. Staff should be mindful that exposing arms and legs may not be acceptable to certain religious and cultural groups and breach accepted standards of modesty. In Endoscopy, for patient safety, the recovery area is one single environment with staff mindful of maintaining privacy and dignity. Patients have access to personal en suite bathrooms with a lockable door. Changing areas will be single sex with lockable doors. Curtains must be well fitted with no gaps. Hems are to be no more than 12 inches from the floor. Patients will be advised that they may bring in dressings gowns if they wish Separate male and female bathrooms will be provided in all departments Exceptions to the above may be acceptable in the case of very minor procedures where patients are not required to undress or otherwise be exposed. 6.3. Transgender, transsexual and intersex service users 6.3.1. Transsexual people, individuals who have proposed, commenced or completed reassignment of gender, are legally protected against discrimination. This protection does not depend on a person having had medical treatment. Others, perceived as, or associated with, transgender people, are also protected. 6.3.2. Transgendered and intersex patients should be accommodated according 12

to their presentation (the way dress, and the name and pronoun they currently use). 6.3.3. This presentation may not always accord with physical sex appearance of the chest or genitalia. 6.3.4. Where admission/triage staff are unsure of a person s gender, where possible, they should 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. 6.3.5. It does not depend upon them having a Gender Recognition Certificate (GRC) or legal name change. 6.3.6. If 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. 6.3.7. Legislation applies to toilet and bathing facilities(except, for instance, that pre- operative trans people should not be required to share open shower facilities). 6.3.8. Views of family members may not accord with the trans person s wishes, in which case, the trans person s view takes priority. 6.3.9. The policy of accommodation according to gender presentation may only be varied under special circumstances 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. 6.3.10. This may arise, for instance, 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. 6.3.11. 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. 6.3.12. At all times this should be done according to the wishes of the patient, rather than the convenience of the staff. 6.3.13. Concerns raised by any patient, relative or carer should be discussed with the ward sister or member of staff in charge of the area and escalated to senior staff as appropriate. 6.4. Children and young adults 6.4.1. Young people between the ages of 12-16 years should not be placed in 13

mixed sex bays unless there is clear clinical need. 6.4.2. The preferences for children aged 11 or older will be taken into account when allocating beds and this choice will be recorded in the ward admission sheet. 6.4.3. Bathroom facilities need not be designated as same sex within the children s ward so long as they only accommodate one patient at a time and can be locked by the patient with an external override for emergency use only. 6.4.4. In the children s ward where patients stay overnight this may mean that other children may share sleeping accommodation with parents of the opposite sex. Staff will ensure this has been taken into account and does not cause anxiety or embarrassment for any child. 6.5. Justifiable breaches 6.5.1. Mixing of male and female patients in the same sleeping accommodation may be justified (i.e. NOT a breach) if it is in the overall best interest of the patient to receive rapid specialist treatment and same sex accommodation is not the immediate priority. At the Trust a breach is considered justifiable in the following emergency clinical circumstances: The need for a monitored or acute stroke bed due to a life threatening emergency either on admission or a sudden deterioration. The need for a critical care bed The need for BiPAP respiratory support only provided within Acute Care Unit and Lamb Wards The need for close observation within the recovery ward following a surgical procedure On the joint admission of couples. 6.5.2. In these cases privacy and dignity must be protected and consideration given to other patients within the mixed area. 6.5.3. One male patient placed within a 6-bedded female bay constitutes 6 breaches in total as all the patients are affected. 6.5.4. The senior manager on call is the accountable officer for authorising a breach of DSSA. 6.6. Not justified breaches 6.6.1. There is no justification for placing a patient in mixed-sex accommodation where this is not in the best overall interests of the patient. For example: Placing a patient in mixed-sex accommodation for the convenience of staff, or from a desire to group patients within 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 estate Placing a patient in mixed-sex accommodation because of a shortage of beds 14

Placing a patient in mixed-sex accommodation because of a predictable non-clinical incident for example a 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 Placing a patient in mixed-sex accommodation on a take it or leave it approach Custom and practice. 6.6.2. In the event that a patient who is fit for transfer to a ward, is in a critical care or theatre recovery area for more than two hours without clinical justification, this is defined as a same sleeping accommodation breach and must be reported. 6.7. Reporting and monitoring breaches of DSSA 6.7.1. The senior manager on call as the accountable officer for authorising a breach of DSSA is responsible for completing a DSSA breach exception report (Appendix 1). This report must include patient level data of all patients affected. 6.7.2. All breaches are reported to the Chief Nurse who will forward the exception report to commissioners. 6.7.3. Breach performance reports will be monitored via Patient Experience Committee and displayed on the Trust website. 6.7.4. Breaches are reported and monitored as section 9. 7 Training and awareness 7.1. Training and awareness for privacy and dignity is provided in the following ways: Corporate induction Nursing preceptorship programme Included in Trust training such as Dementia and Safeguarding National yearly Dignity Awareness Day 8 Review This policy will be reviewed in 3 years time. Earlier review may be required in response to exceptional circumstances, organisational change or relevant changes in legislation or guidance. 15

9 Reporting and monitoring Single Sex Breaches Report/Monitoring/Audit Frequency of monitoring Responsibility for performing the monitoring Exception report Real time Senior manager on call Compliance Annual NHS City & Hackney CCG Real time monitoring 4 times daily Clinical site managers National report via Unify2 Monthly Information team Performance reports Weekly and monthly Information team Patient surveys Continuous; collated & analysed quarterly Head of patient Experience Monitoring reported to: groups/committees, inc responsibility for reviewing action plans Chief Nurse, Business Development Manager, information team and commissioners. Clinical Quality Review Meeting CSM report mailing group Nationally and regionally Divisions, executive team, commissioners Patient Experience Committee National survey Annual Corporate Nationally Privacy and dignity Monitoring/Audit Frequency of monitoring Responsibility for Performing the monitoring Monitoring reported to: groups/committees, inc responsibility for reviewing action plans Picker Patient surveys Trust schedule of surveys; Quarterly Trust reports Head of Patient Experience Patient Experience and Engagement Committee Complaints and PALS Quarterly Public Involvement & Information Manager Rounding Quarterly Heads of Nursing/Midwifery Performance reports Patient Experience and Engagement Committee Patient Experience and Engagement Committee Monthly Chief Nurse Board of Directors, Governors, Commissioners National surveys Annual Corporate Patient Experience and Engagement Committee 10 References and related Policies 16

A letter from the Chief Nursing Officer into mixed sex accommodation in hospital, Department of Health 2007 A refreshed Equality Delivery System for the NHS : EDS2, 2013, Department of Health Dignity in Care, 2006, Department of Health Essence of Care 2010, 2010,Department of Health The Operating Framework for the NHS in England 2012/13, Department of Health Gender Recognition Act, 2005 Human Rights Act, 1998 Mixed-Sex Accommodation NHS England https://www.england.nhs.uk/statistics/statistical-work-areas/mixed-sexaccommodation/ Trans and Intersex People. Discrimination on the grounds of sex, gender identity and gender expression, 2012, European Union Trust Policies Carers Policy (2015) Confidentiality Code of Conduct (2016) Mental Capacity Act and Mental Capacity Act (MCA) and Deprivation of Liberty safeguards (DOLS) Policy (2017) Mobile Phone Policy- General use (2013) Patient Visiting Policy (2016) Safeguarding Vulnerable Adults (2017) Trust Chaperone Policy (2016). Appendix 1 SINGLE SEX ACCOMMODATION BREACH EXCEPTION REPORT The Trust is required to report breaches to commissioners. This exception report is to be completed by the senior manager on call whenever a breach occurs and e-mailed to darrien.bold@homerton.nhs.uk within 3 working days of the breach occurring. All breaches must be authorized by the senior manager on call and most only occur where there is a clinical risk to the patient (or other patients) by not waiting until the correct gender bed is available; that is: need for a monitor / CCU bed, an acute stroke bed, or for advanced respiratory support (BIPAP / NIV). 17

Ward: Date: Time: No of pts: Patients affected: Gender Hosp No DoB Duration 1 2 3 4 5 6 Up to 2 hrs Up to 4 hrs Up to 6 hrs > 6 hrs Reason for breach CCU / monitor Stroke BIPAP / NIV Other comments Name Signature 18

Equalities Impact Assessment This checklist should be completed for all new Corporate Policies and procedures to understand their potential impact on equalities and assure equality in service delivery and employment. Policy/Service Name: Author: Role: Directorate: Trust Privacy and Dignity Policy (incorporating Single Sex Accommodation) Margaret Howat Head of Patient Experience Corporate Date 18.01.2017 Equalities Impact Assessment Question 1. How does the attached policy/service fit into the trusts overall aims? Yes No Comment Meets requirements for national, regional and local patient experience imperatives. 2. How will the policy/service be implemented? 3. What outcomes are intended by implementing the policy/delivering the service? 4. How will the above outcomes be measured? Through existing awareness training and dissemination through divisions. High quality patient care and experience. Through a range of processes as stated in the policy 5. Who are they key stakeholders in respect of this policy/service and how have they been involved? 6. Does this policy/service impact on other policies or services and is that impact understood? 7. Does this policy/service impact on other agencies and is that impact understood? Trust staff and Governors were consulted as part of the development of the policy and have been consulted for the update. This dovetails with a number of policies but does not conflict. See section 4 8. Is there any data on the policy or service that will help inform the EqIA? There is a range of evidence supporting the need for the policy that can be provided. 9. Are there are information gaps, and how will they be addressed/what additional information is required? 19

Equalities Impact Assessment Question 10. Does the policy or service development have an adverse impact on any particular group? 11. Could the way the policy is carried out have an adverse impact on equality of opportunity or good relations between different groups? Yes No Comment 12. Where an adverse impact has been identified can changes be made to minimise it? N/A 13. Is the policy directly or indirectly discriminatory, and can the latter be justified? 14. Is the policy intended to increase equality of opportunity by permitting Positive Action or Reasonable Adjustment? If so is this lawful? EQUALITIES IMPACT ASSESSMENT FOR POLICIES AND PROCEDURES 2. If any of the questions are answered yes, then the proposed policy is likely to be relevant to the Trust s responsibilities under the equalities duties. Please provide the ratifying committee with information on why yes answers were given and whether or not this is justifiable for clinical reasons. The author should consult with the Director of HR & Environment to develop a more detailed assessment of 20

the Policy s impact and, where appropriate, design monitoring and reporting systems if there is any uncertainty. 3. A copy of the completed form should be submitted to the ratifying committee when submitting the document for ratification. The Committee will inform you if they perceive the Impact to be sufficient that a more detailed assessment is required. In this instance, the result of this impact assessment and any further work should be summarised in the body of the Policy and support will be given to ensure that the policy promotes equality. 21

Policy Submission Form Policy Submission Form To be completed and attached to any policy or procedure submitted to the Trust Policy Group 1 Details of policy 1.1 Title of Policy: Trust Privacy and Dignity Policy (incorporating Single Sex Accommodation) 1.2 Lead Executive Director Chief Nurse and Head of Governance 1.3 Author/Title Margaret Howat, Head of Patient Experience 1.4 Lead Sub Committee Improving Patient Experience and Engagement Committee 1.5 Reason for Policy To provide clear standards for all staff in the delivering of patient care that respects privacy and dignity. 1.6 Who does policy affect? All staff; all patients and their carers / family. 1.7 Are national guidelines/codes of practice incorporated? 1.8 Has an Equality Impact Assessment been carried out? 2 Information Collation 2.1 Where was Policy information obtained from? Yes Yes National guidance and best practice evidence from a range of sources. 3 Policy Management 3.1 Is there a requirement for a new or revised management structure if the policy is implemented? No 3.2 If YES attach a copy to this form N/A 3.3 If NO explain why N/A Policy is already in place this is a review 4 Consultation Process 4.1 Was there internal/external consultation? Yes 4.2 List groups/persons involved Improving Patient Experience and Engagement Committee Chief Nurse and Director of Governance Heads of Nursing/ Midwifery Head of Adult Safeguarding Head of Children Safeguarding Senior nurses/midwives / lead nurses/ sisters / charge nurses 4.3 Have internal/external comments been duly considered? Yes 22

4.4 Date approved by relevant Subcommittee 4.5 Signature of Sub committee chair 5 Implementation 5.1 How and to whom will the policy be distributed? Via internet and email cascade 5.2 If there are implementation requirements such as training please detail? Covered within present training process 5.3 What is the cost of implementation and how will this be funded? No Cost 6 Monitoring 6.1 List the key performance indicators for example core standards Eliminating mixed sex accommodation Dignity in Care 6.2 How will this be monitored and/or audited? Monitoring set out in policy 6.3 Frequency of monitoring/audit As set out within the policy 23