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Delivering Single Sex Accommodation Policy (DSSA) Version: 8.1 Issue Date:11 December 2017 Review Date:10 December 2020 (unless requirements change) of 35

DELIVERING SINGLE SEX ACCOMMODATION (DSSA) POLICY

Version 8.1

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

Related Procedural Documents Policy for the Management of Adverse Incidents and Near Misses

Key Words (to aid with searching) Privacy and Dignity

Version Tracking Version Date Ratified Brief Summary of Changes Author

8.1 01.10.2019 Appendix 1 updated and logos updated L.Hall

8 09.11.2017 Updated guidance for use of screens L.Hall

7 09.03.2017 Updated guidance for Day Units when opened as escalation areas and RHCU for level 1 patients. RAG

Breach ratings added for each area.

Electronic location changed to Clinical Policies

L. Hall

6 22.03.2016 Updated quick reference flowchart and guidance for transgender, ITU and recovery patients.

L. Hall

5 01.02.2014 Updated references J Sprack


CONTENTS QUICK REFERENCE GUIDE ............................................................................................................. 3

1. INTRODUCTION.......................................................................................................................... 5

2. PURPOSE ................................................................................................................................... 5

3. SCOPE ........................................................................................................................................ 5

4. DEFINITIONS .............................................................................................................................. 5

5. DUTIES AND RESPONSIBILITIES .............................................................................................. 6

6. PROCESS ................................................................................................................................... 7

7. AREAS AFFECTED BY THIS POLICY ........................................................................................... 9

8. DELIVERING SAME-SEX ACCOMMODATION FOR TRANS PEOPLE AND GENDER VARIANT CHILDREN................................................................................................................................. 11

9. TRAINING REQUIREMENTS .................................................................................................... 12

10. REFERENCES AND ASSOCIATED DOCUMENTATION .......................................................... 13

11. EQUALITY IMPACT STATEMENT ............................................................................................ 13

12. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS ........................................ 14

Appendix 1 - WRITTEN APOLOGY TO BE GIVEN TO THE PATIENT ............................................. 15

Appendix 2: SINGLE SEX BREACH ROOT CAUSE ANALYSIS ....................................................... 17

Appendix 3: OPERATIONAL GUIDANCE CHAT CSC ...................................................................... 21

Appendix 4: OPERATIONAL GUIDANCE FOR CARDIAC DAY UNIT (CDU) ................................... 28

EQUALITY IMPACT SCREENING TOOL ......................................................................................... 34


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


Initial Investigation Panel • CSC to ensure Single Sex IMR/Root Cause Analysis is completed, including a layout of the area and forwarded

to the Risk Department and Lead Nurse for DSSA. • CSC to arrange a panel, including Lead Nurse DSSA, chaired by Director of Nursing or Deputy Director of

Nursing • Establish if the breach was clinically justified for patient safety reasons or not, and/or whether sleeping

accommodation or bathroom facilities were breached. Check if breach avoided by use of Kwick screens • Confirm patients have received a letter of apology • RCA returned to author for any final amendments

POTENTIAL SINGLE SEX BREACH

Final panel to be held (within 6 weeks of Initial Investigation Panel meeting

Not Clinically Justified

OUT OF HOURS • Escalate to DHM and Duty Matron/H@N before a

breach occurs

• DHM to consult with On Call Manager to explore all options to avoid a breach

• Clinically Justified breaches for non-eligible areas

• Facilities breaches • Lead Nurse DSSA to update Single Sex Breach

Spreadsheet on Operation Centre G Drive and inform BI • Business Intelligence to report nationally on Unify 2 • Lead Nurse for DSSA to report on monthly Quality

Report • All breaches to be monitored through the routine quality

contract monitoring meetings with commissioners and local action plans.

• CSCs to monitor completion of actions via CSC Governance meetings

• Lead Nurse for DSSA to monitor actions and identify key themes for learning and education Trustwide

• Check eligibility criteria for the area as per this policy e.g. acceptable justification areas • All actions must be explored by the CSC and DHM to avoid a single sex breach. • Establish type of breach (sleeping accommodation or bathroom facilities) • A breach occurs at the point a patient is admitted to a mixed sex accommodation which is not clinically justified

or bathroom facilities are not single sex.

If a breach: • The breach and the number of patients affected must be reported at the next Operational Meeting • Immediate/remedial actions agreed to resolve the breach as soon as possible within 24hrs • Utilise Kwick screens to segregate males/females to protect their privacy and dignity and follow local guidance

for escalation areas e.g. CDU, RHCU, RDU and Recovery. If used effectively screens can prevent a breach. • CSCs Management team or Duty Matron/DHM, Out of Hours, to provide an explanation and apology to the

patient in person followed by a letter (see Appendix 1). • Safety Learning Event Form to be completed initially graded as an ‘amber’ incident • Lead DSSA Nurse to enter the patient details on the Operation Centre Single Sex report spreadsheet • Safety Learning Event Form to be completed, initially graded as ‘amber’ incident

IN HOURS • Escalate to Speciality Matron/Head of Nursing

before a breach occurs.

• Lead Nurse DSSA to report to Commissioners via the monthly Quality Report

• 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 breaches monitored through the routine quality contract monitoring meetings with commissioners and local action plans.

•


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 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 t hrough, 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.

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.

• 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 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

Red

A Single Sex Accommodation breach is never acceptab le 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.

Amber

A Single Sex Accommodation breach is occasionally a cceptable/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.

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 Depa rtment 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 Area s (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 CHAT Outlier SOP: http://pht/Departments/DaySurgery/Standard%20Operating%20Procedures%20Documents%

Never

Red

Never

Red

Sometimes

Amber

Sometimes

Amber

Almost always

Green

Almost always

Green

Sometimes

Amber

Never

Red

Never

Red


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 PEOP LE 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 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

Sometimes

Amber

Sometimes

Amber


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 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/Publicationsandstatistics/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.


12. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

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

Minimum requirement to be monitored

Lead Tool Frequency of Report of Compliance

Reporting arrangements Lead(s) for acting on Recommendations

RCAs relating to non-compliance

CSC Management team

Single Sex Breach Root Cause Analysis

When a breach occurs 48 hr. Panel to be organized and chaired by executive

Monthly & Annual Quality Report

Unify for any breaches

CSC Management team

Lead Nurse for DSSA and Head of Nursing for Children and Young People 0-19years

Daily checks of escalation areas by Duty Matron and Hospital @Night

Director of Nursing

Daily staffing sheets Daily Escalate as per DSSA flowchart to resolve any concerns.

Monthly & Annual Quality Report

CSC Management team

Duty Hospital Managers

Lead Nurse for DSSA

Inpatient survey results Head of Patient Experience

Annual Inpatient Survey Annual Annual Quality Account

Governance and Quality Committee

Associate Director of Quality and Governance.

Head of Patient Experience


Patient feedback through FFT, PALS and complaints


Complaints

FFT Results

Annual Quality Account

Governance and Quality Committee Associate Director of Quality and Governance.




Appendix 1 - WRITTEN APOLOGY TO BE GIVEN TO THE PAT IENT


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 time

Date and length of occurrence

Incident Number:

State of Hospital Green/ Amber/Red/Black Number of medically fit patients awaiting discharge

Date occurrence reported to Lead Nurse

Duration:

Ward and CSC

Supplementary Information

Breach Patient Details

Name NHS Number

Address Male/ Female

Name NHS Number


Name NHS Number


Name NHS Number


Affected Patient Details

Name NHS Number


Name NHS Number



Name NHS Number


Name NHS Number


Admission Method ( � where appropriate):

Emergency Elective

Effect on Patients

Was this occurrence clinically justified?- please refer to policy before completing

Safety

Acuity

Specialist Care or observation

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


Escalated to Duty Director - name

Written apologies issued - by whom

Good Practice

Care Delivery/Service Delivery Problem

(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 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 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

Conclusion of panel

Justified due to- Not justified and declared to Commissioners-

Panel Membership Name Job Title


Appendix 3: OPERATIONAL GUIDANCE CHAT CSC

Delivering Same Sex Accommodation (DSSA) - Operatio nal 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:-


Red A Single Sex Accommodation breach is never acceptab le 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 a cceptable/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 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) B reach Matrix

Breach Risk

Actions and Confirmation of Breach Criteria

Comments ITU Recovery Day Surgery Unit and

Theatre Admissions

Red HIGH BREACH RISK • Breaches will not be reported unless they are not clinically justified (e.g. for capacity).

• In Level 2 and 3 units the clinical

justification no longer applies once a decision has been made to transfer the patient to level 1 care (if the move is undertaken out with the normal and agreed practice with the CCG). The clinical justification will still apply if the medical consultant has advised that it is not in the patients best interests to move them within the unit to prevent a breach.

• Escalate to: In Hours to the senior

management teams (Band 7, Matron, Operational Manager, Clinical Director �CSC Management Team out of Hours (OOH) – Duty Hospital Manager (DHM) and/or Hospital at Night Team (H@N).

• Impending Single Sex Accommodation

beaches will be discussed at Hospital Operations Meeting if the plans by the Senior Management Team may be compromised due to hospital pressures (this is particularly important for the Out of Hours periods).

• Clinically and non-clinically justified

Patient breaches when an individual patient is fully ready and referred for ward care over 24 hours and cannot/or is not already accommodated in a single room/cohorted bed space.

Patient breaches when 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 surgical outliers overnight as per the Trust escalation policy refer to the CHAT Outlier policy http://pht/Departments/DaySurgery/Standard%20Operating%20Procedures%20Documents%20SOPs/Forms/AllItems.aspx which provides more detailed information about how to segregate recovery to comply with single sex accommodation guidelines which includes floor plans (see page 4 for an example).

When Day Surgery Unit 2nd stage is being utilised for bedded inpatients if not patients of the same sex.

ACTIONS TO BE TAKEN TO AVOID PRIVACY AND DIGNITY BR EACH Keep patient accommodated within a single room/ cohorted bed space if appropriate (and if other patients care is not compromised as a result).

• Cohort patients waiting discharge if clinically safe and possible (if not being used consider bays 15/16, 22/23 or paediatric recovery);

• 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.

N/A – if this was being used and patients were mixed it would constitute a breach.


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

sleeping and facilities breaches will always be reported via an amber Safety Learning event on Datix.

• Notify the Trust DSSA lead.

• The CSC should arrange the panel ideally

within 48hrs as per the Trust policy

• If a breach has occurred follow the Trust Policy for notifying the patient and following-up with a letter of apology.

Amber MEDIUM BREACH RISK – CLINICALLY APPROPRIATE Patients ready for ward care but within 24 hours of referral. Extra attention will be given to ensuring their privacy and dignity by use of curtains, cohorted bed space etc.,

Patients meet discharge criteria and are more alert but not at mobilisation stage, therefore privacy and dignity met by cohorting patients waiting discharge and using screens and curtains.

Consideration being made to open Day Surgery Unit for bedded inpatients. Segregate long stay patient’s male/female within the area.

Green LOW BREACH RISK – CLINICALLY APPROPRIATE All patients admitted to Critical Care whatever their level of care will have consideration re: Single Sex Accommodation issues. Their privacy and dignity will be maintained at all times.

Patients not breaching as actions taken to maintain privacy and dignity.

Male/Female patients are not placed opposite each other (i.e. in close proximity and in direct view) to avoid accidental exposure of the opposite sex. Appropriate screens are in place.

Patients not breaching but maintaining privacy and dignity levels.

Male/Female patients are not placed opposite each other (i.e. in close proximity and in direct view) as far as is practicably safe. Utilisation of screens and curtains.


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.

In - Hours Patient Ready for Discharge from Recovery –

Ward/Clinical Area contacted

Patient not collected within 30 mins

Patient collected within 30 mins

> 30 mins Escalate to Specialty Patient

Flow Manager

> 45 mins Escalate to the Specialty Matron

and Specialty Operation/Business Manager

> 60 mins Escalate to the Specialty Head of Nursing and/or General Manager

• Patients > 45 mins will be moved to an area where privacy of themselves and other patients may be maintained whilst they can be safely cared for, i.e. 2 bays in bariatric bay area or paediatric bay if no paediatric list the next day.

• If patients cannot be moved and remain in the main recovery area overnight privacy and dignity must be maintained by using curtains and screens

• For significant periods of times cold meals can be arranged via catering before 1800. Hot drinks and water need to be provided.

• Designated male/female toilet facilities should be used via the E17 corridor. • Inform relatives so they are not worried and give advice on visiting to minimise impact on other

patients in recovery. • A list of the patient details needs to be submitted, discussed and actions agreed at the 0830 Hospital

Operational meeting and reviewed at regular intervals

> 60 min Escalate to the CHAT CSC Head of Nursing and/or General Manager

> 45 mins Escalate to the Theatres Senior Clinical Manager/Matron and/or Clinical Services

Depending upon delay in move, numbers of patient within recovery and necessity to move

across patient areas of an opposite sex - consider logging a single-sex breach


Appendix 4: OPERATIONAL GUIDANCE FOR CARDIAC DAY UNIT (CDU) Delivering Single Sex Accommodation (DSSA) – Operat ional 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:-


Red (Never) A Single Sex Accommodation breach is never acceptab le 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 (Sometimes)

A Single Sex Accommodation breach is occasionally a cceptable/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 due to clinical urgency

Green (Almost always)

Usually justified/acceptable e.g. • Elective admissions where 7 or less single gender admissions booked • 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, 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.

Breach Risk

Actions and Confirmation of Breach Criteria Comments

Elective capacity only Unfunded escalation capacity

Red HIGH BREACH RISK An Acceptable Justification i.e. not a breach can be applied (in line with the Trust policy sections 6.4, 6.5.1, 6.5.2 and 6.5.3) for the following reasons:

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 or Cath Lab available. Privacy and dignity must be protected- e.g. use of mobile privacy screens where safe and appropriate.

• In all instances, escalate to: In Hours the CDU management teams (Band 7, Matron, Operational Manager, Clinical Director

Patient breaches occur when more than 7 patients of one gender are admitted and are mobilising post procedure as part of their recovery or to use bathroom facilities (if walking visibly across the path of a patient of the opposite sex).

Potential breaches will occur when CDU is being utilised for bedded inpatients if patients are not of the same sex and screens are not in use. The risk of accidental exposure to the opposite sex increases when the number of inpatients is over 7.

ACTIONS TO BE TAKEN TO AVOID PRIVACY AND DIGNITY BREACH • Single sex lists where practicable • If single sex lists not practicable use privacy

screens as per CDU “Mixed Sex Accommodation breach avoidance” guidance maps (see page 4). .

• Medical outliers will be single sex and limited to 7.

• Elective lists to be single sex and the same sex as the outliers where practicable

• If mixed sex lists are unavoidable due to


• 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.

• Use Cath Lab lounge suits for all patients – this will ensure privacy and dignity whilst the patient is safely prepared for/recovering from their procedure

waiting list constraints the use of privacy screens must be used to segregate sleeping and bathroom facilities (as per CDU “Mixed Sex Accommodation breach avoidance” guidance maps (see page 4).

• Use Cath Lab lounge suits for all elective patients if they are of the opposite sex to other patients on the list and the inpatients

�CSC Management Team Out of Hours (OOH) – Duty Hospital Manager (DHM) and/or Hospital at Night Team (H@N).

• Escalate any impending Single Sex Accommodation breaches at the Hospital Operations Meeting if the plans by the Senior Management Team may be compromised due to hospital pressures (this is particularly important for the Out of Hours periods).

• Clinically and non-clinically justified sleeping and facilities breaches will always be reported via an amber Safety Learning event on Datix.

• Notify the Trust DSSA lead. • The CSC should arrange the panel ideally

within 48hrs as per the Trust policy • If a breach has occurred follow the Trust

Policy for notifying the patient and following-up with a letter of apology.

Amber MEDIUM BREACH RISK – CLINICALLY APPROPRIATE Patients meet discharge criteria and are more alert but not at mobilisation stage, therefore privacy and dignity met by cohorting patients waiting discharge and using screens and curtains.

Consideration being made to open CDU for bedded inpatients. Segregate long stay patients from elective male/female patients within the area.

ACTIONS TO BE TAKEN TO AVOID PRIVACY AND DIGNITY BR EACH • 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 gender admitted but actions taken to maintain privacy and dignity.

Patients not breaching if single sex only throughout CDU but maintaining privacy and dignity levels.


EQUALITY IMPACT SCREENING TOOL To be completed and attached to any procedural docu ment when submitted to

the appropriate committee for consideration and app roval 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

Department Corporate

Name of person completing assessment

Liz Hall Job Title Lead Nurse DSSA and Head of Nursing for CHAT

Does the policy/function affect one group less or m ore favourably than another on the basis of :

Yes/No Comments

• Age No

• Disability Learning disability; physical disability; sensory impairment and/or mental health problems e.g. dementia

No

• 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

What is the impact Level of Impact

Mitigating Actions (what needs to be done to minimise /

remove the impact)

Responsible Officer

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