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									FIVE STEPS TO
ELIMINATING MIXED-SEX
ACCOMMODATION




                        PROGRAMME SUMMARY AND
                        COLLECTED CURRENT GUIDANCE
                        AUGUST 2010
                    PRINCIPLES OF                                                                  PRINCIPLES FURTHER DETAIL:
                    SAME-SEX ACCOMMODATION                                                         8.   On mixed-sex wards, bedroom and bay areas should be clearly designated as male
                    FOR INPATIENT SERVICES                                                              or female.
                    (DH, 2010E)                                                                    9.   In all areas, toilets and bathrooms should be clearly designated as male or female.

                                                                                                   10. When mixing of the sexes is unavoidable, the situation should be rectified as soon as
                                                                                                       possible. The patient, their relative, carers and / or advocate (as appropriate), should be
                                                                                                       informed why the situation has occurred, what is being done to address it, who is dealing
                                                                                                       with it and an indication provided about when the situation will be resolved.
               1. There are no exemptions from the need to provide high
                  standards of privacy & dignity.                                                  11. Patients / service users should be protected at all times from unwanted
                                                                                                       exposure, including being inadvertently overlooked or overheard.
               2. Men and women should not have to sleep in the same room,
                  unless sharing can be justified* by the need for treatment (see                  12. Patient preference regarding mixing should be sought, recorded and where possible
                                                                                                       respected. Ideally this should be in conjunction with relatives or loved ones.
                  point 14 in further detail), or by patient choice. Decisions
                  should be based on the needs of each individual, not the                         13. There may be circumstances that require additional attention to be given to help patients/
                  constraints of the environment, nor the convenience of staff.                        service users retain their modesty, specifically where:

               3. Where mixing* of sexes does occur, it must be acceptable and                     •    They are wearing gowns or nightwear, or where the body might become exposed
                  appropriate for all the patients affected.                                       •    They are unable to preserve their own modesty, e.g. recovery from general anaesthetic
                                                                                                        or when sedated
               4. Men and women should not have to share toilet and washing
                  facilities with the opposite sex, unless they need specialised                   •    They cannot judge for themselves, for whatever reason
                  equipment such as hoists or specialist baths.                                    14. Any circumstance that constitutes clinical justification for mixing of the sexes is for local
                                                                                                       determination. Generally, for acute services, justification might relate to “life or death”
               5. Men and women should not have to walk through the
                                                                                                       situations, or a patient needing highly technical or specialist care / one to one nursing.
                  bedrooms / bed bays or bathroom / toilets of the opposite sex
                                                                                                       (e.g. ICU, HDU). There is no clinical justification for mixing in mental health and learning
                  to reach their own sleeping, washing or toilet facilities.                           disability services.
               6. Staff should make it clear to the patient that the Trust                         15. Where family members are admitted together for care, they may, if appropriate, share
                  considers mixing to be the exception, never the norm.                                bedrooms, toilets and washing facilities.

               7. Changes to the physical environment (estates) alone will not                     16. In mental health and learning disability services there should be provision of women-only
                  deliver same-sex accommodation; they need to be supported                            day rooms on wards where men and women share day areas.
                  by organisational culture, systems and practice.                                 17. For many children and young people, clinical need, age and stage of development may take
                                                                                                       precedence over gender considerations. In mental health and learning disability services,
                                                                                                       boys and girls should not share bedrooms or bed bays, and toilets / washing facilities
                                                                                                       should be same-sex. An exception to this might be if a brother and sister were to be admitted
                                                                                                       onto a children’s unit. Here, the sharing of bedrooms, bathrooms or toilet areas may be
                                                                                                       appropriate.

                                                                                                   18. Transgender people should be accommodated according to their presentation; the way
                                                                                                        they dress, the name and pronouns that they currently use.


*There is no clinical justification for mixing in mental health and learning disability services
                                                                                                                                                                                                       03
CONTENTS

Principles of same-sex accommodation                                            02

Contents                                                                        04

Foreword                                                                        06

The 5 steps to eliminating mixed-sex accommodation:

   1. A declaration of compliance (or non-compliance) is required               09

   2. A delivery and improvement plan must be in place                          11

   3. “Breaches” should be understood, measured and reported                    12

   4. Collection of patient experience data is required                         15

   5. Ongoing quality monitoring & contract sanctions are mandated              17

Table of solutions by specialty                                                 18

Further Support - Estates                                                       20

Same-sex accommodation project contacts & other support                         21

Same-sex accommodation contact list                                             22

Links to key documents                                                          23

Appendices:

   1. North West regional outputs 2009/10                                       24

   2. DH compliance checklist                                                   25

   3. Contract performance flowchart                                            26

   4. Key contract provisions                                                   27               The “Dignitea” mug; part of the integrated
                                                                                                     improvement campaign at Manchester
   5. Contract sanctions matrix                                                 28                 Mental Health and Social Care NHS Trust,
                                                                                                        led by their Matron Sheila Kasavan.
References                                                                      30

Acknowledgements                                                                31




                                                                                     NOW THE SIGNS ARE UP,
Guidance is correct at the time of writing (August 2010).                            THE STAFF KNOCK BEFORE
All references to the NHS standard contract refer to 2010/11 (acute) version.        THEY ENTER
                                                                                     Service user, Manchester.




                                                                                                                                        05
   FOREWORD




We know that when people are in hospital they may feel            There is also some emerging anecdotal evidence from around
particularly vulnerable. In a recent national patient survey,     the country that by increasing dignity & privacy, a range of
18% of patients felt that their dignity and privacy had been      additional benefits may be seen. For example:
compromised (CQC, 2010a). Hospital patients have strongly
                                                                  •   Reduced noise levels in bed areas
expressed that they do not like sharing intimate space such as
                                                                  •   Reduction in the number of falls
sleeping and bathing areas, and have said that if this happens
                                                                  •   Increased nurse observation
they want to be told why. It is worthy of note that whilst this
                                                                  •   A calmer ward atmosphere
is a clear preference, patients rarely complain about sharing.
                                                                  •   Support for infection control
As one hospital patient put it;                                   •   Reduction of delayed discharge

“When you come in you are too poorly to                           Eliminating mixed-sex accommodation gives us a wonderful
care. When you move on you are grateful to                        opportunity to continue improving services for people who
be getting better. When you are discharged                        use them. We have described the five simple steps which
you are just happy to be going home. It is only                   assure this is achieved. These steps lead naturally into continuing
afterwards that you think about it and feel                       the improvements across the wider dignity and privacy agenda.
embarrassed”
                                                                  We know that NHS staff are totally committed to this, and
The commitment to same-sex accommodation in the NHS               keen to build on the improvements they have already made.
dates back to 1997. In January 2009, a number of additional       We hope that this booklet will help to deliver those aims.
measures were put in place to ensure that these patient
preferences were supported (DH 2009a). This included financial
investment, robust contract levers and practical support. The
project outputs for this period are summarised in Appendix 1.

The revision to the Operating Framework for the NHS in
England 2010/11 (DH, 2010d) makes it clear that eliminating
mixed-sex accommodation continues to be a priority. This is                                                                   Jane Cummings
reflected in the NHS standard contract and was recently                                    Chief Nurse and Executive Director of Performance,
                                                                                                                    Quality & Commissioning,
confirmed by the Secretary of State for Health.                                                                               NHS North West

Eliminating mixed sex accommodation is the right thing for
patients and service users, and it is what we would want for
our own families and loved ones. Many NHS staff have told us
that they use a basic “rule of thumb” to help them protect
people’s dignity. They ask themselves; “Would I be happy                                                                                         Colour coded bay doors have the
                                                                                                                                                     additional benefit of helping
with this experience for my loved one?” It is a very simple but
                                                                                                                                                people with cognitive impairment
effective question.                                                                                                                                    correctly navigate an area.




                                                                                                                                                                                     07
    1.
                       A DECLARATION OF COMPLIANCE
                       (OR NON-COMPLIANCE)
                       IS REQUIRED

By March 2010, every NHS provider with inpatient beds was required to complete a
declaration of compliance or non-compliance and post it on their website (DH, 2010c). The
declaration is a “condition precedent” to the NHS standard contract – failure to have one could
put an organisation in automatic breach of contract, which could lead to withholding
payment under 31.1. In the North West, every provider made a declaration of compliance.

 INDICATORS OF COMPLIANCE                                       SAME-SEX ACCOMMODATION CAN BE
 The following list was identified by the NHS North West        PROVIDED IN:
 Delivering Same-Sex Accommodation (DSSA) project board
                                                                • Same-sex wards
 as the necessary elements to indicate compliance to
 same-sex accommodation.                                        • Single rooms with adjacent same-sex washing and
                                                                  toilet facilities
 1. Strategic commitment; same-sex accommodation is the
    norm and there are agreed plans to deliver it               • Same-sex bays or rooms with designated same-sex
                                                                  toilet and washing facilities
 2. Virtual elimination of mixing is demonstrated in wards,
    assessment units and day facilities                         • No “crossflow” – people must not pass through the
                                                                  space of another gender to reach their facilities
 3. There is an ongoing process to measure ALL
                                                                  (DH, 2010c Annex)
    occurrences of mixing (breaches), reported to Trust
    board & commissioner                                        • Intensive care and A&E are not included, for practical
                                                                  reasons.
 4. Patient experience is measured and reported to Trust
    board & commissioner
 5. There is a process for investigating the rare occurrences   “VIRTUAL ELIMINATION” OF MIXING
    of mixing when not clinically justified (eg root cause      Any mixing should be the exception, not the norm. The
    analysis, DH/NPSA 2009)                                     definition of virtual elimination should be agreed locally by
                                                                commissioners and providers. Baselines from the mandatory
                                                                collection of mixing (breach) data will be helpful in
 FEATURES OF A ROBUST DECLARATION OF                            determining this. The NHS North West Delivering Same-Sex
 COMPLIANCE                                                     Accommodation (DSSA) project board has agreed that the
                                                                phrase; “virtually eliminated” indicates a low level that is
 • The DH checklist (DH, 2010c Annex 2) was used
                                                                not likely to occur on a daily or weekly basis, unless this is
   systematically to inform the decision [Checklist appears
                                                                clinically justified.
   in Appendix 2]
 • There is evidence to support each statement in the
                                                                THE REGULATORY FRAMEWORK
   checklist
                                                                As the new health and social care regulator for
 • Where evidence is absent, remedial actions appear in
                                                                England, the Care Quality Commission registration
   the plan
                                                                process requires all health and social care providers to
 • If work is in progress, the date for full compliance is      demonstrate that they meet essential standards of
   identified and agreed with the commissioner                  quality and safety. Supporting privacy and dignity is             Glazed panel with an internal
                                                                                                                                   louvre blind. Other obscuring
                                                                covered under Outcome 1 and Outcome 10 (CQC,
                                                                                                                                 methods have included curtains
                                                                2010b).                                                          and nets, etching, film, and the
                                                                                                                                      use of artwork or posters.


                                                                                                                                                                09
                                                                                 2.                 A DELIVERY AND IMPROVEMENT
                                                                                                    (DSSA) PLAN MUST BE IN PLACE

                                                                                In addition to the declaration, every NHS provider must have a plan to support the
                                                                                elimination of mixed-sex accommodation. It should contain clear milestones. (DH, 2010c, DH,
                                                                                2010b) The plan is also a “condition precedent” to the NHS standard contract – failure to have
                                                                                a plan which is agreed by the commissioner could put an organisation in automatic breach of
                                                                                contract, which could lead to withholding payment under 31.1. The plan should detail any
                                                                                areas of challenge and milestones should be agreed by the commissioner. It forms the ideal
                                                                                basis for discussions as part of the quality contract monitoring process. Failure to meet a
                                                                                milestone in the DSSA improvement plan could result in use of clause 32 process to have a
                                                                                Recovery Action Plan (RAP) and sanction as per local determination if RAP is breached.




                                                                                                                                                             DELIVERING SAME-SEX
                                                                                                                                                             ACCOMMODATION IS
                                                                                                                                                             80% CULTURE AND
                                                                                                                                                             20% ENVIRONMENT
                                                                                                                                                             Executive Director, Liverpool.




                                                                                 CONTENTS OF THE DELIVERY AND                                 IF THE PLAN IS NOT MET
                                                                                 IMPROVEMENT (DSSA) PLAN                                      The contract performance process is followed (DH, 2010a
                                                                                 (DH, 2010c; DH, 2010b clause 4.24, 4.25)                     p95). [See flow chart in Appendix 3 for details.]
Clear signage at Leighton Hospital, Crewe, which is part of Mid Cheshire
Hospitals NHS Foundation Trust. It is informed by evidence of what is helpful    • Covers any absent elements from the self-declaration
for people with cognitive impairment, and incorporates the written word, a         checklist
photograph and a symbol. It has been shown to have a range of benefits,                                                                       SUMMARY OF KEY CONTRACT PROVISIONS
for example: increased independent access to toileting facilities, reduced       • Uses baseline breach data
                                                                                                                                              FOR SAME-SEX ACCOMMODATION
incontinence and reduced agitation.                                              • Identifies areas of challenge for same-sex accommodation   (See Appendix 4 for the summary in full)
                                                                                   and actions
                                                                                                                                              DSSA plan: Clauses 4.24, 4.25
                                                                                 • Describes clear activities and timescales
                                                                                                                                              Withholding payment: Clause 7.23
                                                                                 • Is agreed by the commissioner as part of contract
                                                                                                                                              Quality requirement: Schedule 3 Part 4A
                                                                                   requirements
                                                                                                                                              Nationally specified event: Schedule 3 part 4, threshold >0
                                                                                 • Is a living document that develops via the clinical
                                                                                                                                              Conditions precedent: Schedule 4 3
                                                                                   quality review process
                                                                                 • States when full compliance will be achieved




                                                                                                                                                                                                            11
    3.
                          “BREACHES” SHOULD BE
                          UNDERSTOOD, MEASURED
                          AND REPORTED

Any mixed-sex occurrence can be described as a “breach”. Since April 2010, all NHS providers
are required to count and report all occurrences of mixing, whether or not they are clinically
justified. This “breach data” should be collected on a monthly basis and reported to the
provider Trust Board and the commissioner. All mixing (breach) data will be discussed as part
of clause 8 and clause 33 monthly monitoring, inform the improvement plan and define areas
for local action. Through discussion with the commissioner, any non-justified breaches will be
identified and subsequent action will be determined (see contract sanctions Appendix 5). The
threshold for a breach of the same-sex accommodation requirements is >0 (DH, 2010b).
Non-justified breach of same-sex accommodation could lead to recovery of the cost of the
procedure or service received by the patient under clause 7.23, and sanction as per local
determination if the Recovery Action Plan (RAP) is breached.
Where the breach is not clinically justified, the commissioner is required to enforce the
penalties set out in the standard contract (DH 2010f p2). The requirement to deliver same-sex
accommodation is covered in the NHS Operating Framework, (DH, 2010d) therefore sanctions
may apply at all times, including when a contract is still being negotiated.                                                                                                                             A semi-permanent solution at Royal Preston Hospital,
                                                                                                                                                                                                             part of Central Lancashire Teaching Hospitals NHS
                                                                                                                                                                                                      Foundation Trust. These retro-fitted panels provide good
                                                                                                                                                                                                    soundproofing and additional privacy to a previously open
 REPORTING BREACHES                                                “CROSS-FLOW” BREACHES                                                                                                               area. They cause minimal disruption to existing lighting
                                                                                                                                                                                                       and ventilation systems whilst fitting, and can be easily
 • All mixing must be counted by month and reported to             If men and women have to pass through an area                                                                                         removed to facilitate the larger scale reconfiguration
   the commissioner.                                               designated for occupation by members of the opposite sex                                                                                                which is planned in the longer term.
                                                                   to gain access to their sleeping, washing, toilet or
 • Non-justified breaches and the sanctions applied are
                                                                   treatment facilities, this is a “cross-flow” breach. These
   reported each month by the commissioner to NHS
                                                                   areas should be identified using an estates survey such as
   North West using the template provided.                                                                                                                                                                  EFFECTIVE DEMAND &
                                                                   the DSSA status report, which can be found at                DEFINITION OF A MIXED SEX OCCURRENCE
 • Returns are due by the 14th of the following month and          http://nww.northwest.nhs.uk/PrivacyandDignity/         The   (BREACH)                                                                    CAPACITY MANAGEMENT
   are sent to: sha.information@northwest.nhs.uk                   numbers of people affected should be calculated and                                                                                      IS KEY TO ENSURING THE
                                                                                                                                The placement of a patient within a clinical setting
   A monthly return is expected until further notice, even if      reported based on occupancy.                                 following admission, where one or more of the following                     SUSTAINABILITY OF
   there have not been any non-justified breaches.
                                                                                                                                criteria apply:                                                             SAME-SEX ACCOMMODATION
 • The information is sent to DH by NHS North West.
                                                                   HOW TO MEASURE NON-JUSTIFIED                                 a. The patient occupies a bed space that is either next to                  Janice Stevens, National Director, DH.
                                                                                                                                   or directly opposite a member of the opposite gender.
                                                                   BREACHES
 JUSTIFIED BREACHES                                                                                                             b. The patient occupies a bed space that does not have              CASE STUDY PROACTIVE “FLOW”
                                                                   Non-justified breaches are measured according to the
 There are two occasions when a breach of same-sex                                                                                 access to single-sex washing and toileting facilities.           MANAGEMENT USING IT:
                                                                   number of people they affect. Hence, one female in a male
 accommodation is justified:                                       bay with four beds:                                          c. The patient must pass through an area designated for             At East Lancashire Hospitals NHS Trust, using an element
 1. When the need to treat and admit overrides the need for                                                                        occupation by members of the opposite sex to gain
                                                                   ONE occurrence x FOUR people = FOUR breaches                                                                                     of specialist software provides visual management of the
    complete segregation (clinical justification). This only                                                                       access to their own sleeping, washing or toileting facilities.
                                                                   Only one occurrence should be counted for each patient                                                                           flow of patients in real time by using a colour-co-ordinated
    applies to very urgent, highly specialist or high tech care.                                                                   The NHS North West Project Board has agreed that this
                                                                   during their stay.                                              also applies to access to treatment facilities.                  screen shot to represent the gender of the patient. The
 2. For reasons of patient choice                                                                                                                                                                   system can be accessed by staff at all levels. Other elements
                                                                                                                                This applies at all points on a patient’s in-patient pathway
 Where mixing does occur, it must be justifiable for all the                                                                                                                                        of the system are also being used to provide real-time
                                                                                                                                and in all areas. Intensive care and A&E are not included, for
 patients concerned                                                                                                             practical reasons.                                                  patient experience monitoring and satisfaction surveys.

                                                                                                                                                                                                                                                                    13
                                                                                                                                           4.
                                                                                       THE ASSESSMENT AREA PROVIDED
                                                                                                                                                                COLLECTION OF
                                                                                       ME WITH SENSE OF PRIVACY AS                                              PATIENT EXPERIENCE DATA
                                                                                       I WAS NOT IN A WAITING AREA                                              IS REQUIRED
                                                                                       WHILST IN PAIN
                                                                                       Patient, Liverpool.
                                                                                                                                       The patient is the final arbiter of success. The White Paper “Equality and Excellence: Liberating
                                                                                                                                       the NHS” (DH, 2010g) sets out a number of measures to increase the collective voice of
                                                                                                                                       patients and service users. The continuing collection of patient experience measures is already
                                                                                                                                       required as an aspect of compliance to same-sex accommodation, and provides a good fit to
                                                                                                                                       these expectations. Failure to collect patient experience measures may be considered a breach
                                                                                                                                       of information requirements. It could lead to withholding of 2% of the monthly contract value
                                                                                                                                       until the required information is provided, leading to retention.

                                                                                                                                       INCREASING THE COLLECTIVE VOICE OF                             MEASURABLE IMPROVEMENT IN THE REGION
                                                                                                                                       PATIENTS AND SERVICE USERS (DH, 2010G)                         During the national work, patient experience data were
                                                                                                                                       The White Paper; “Equality and Excellence: Liberating the      collected from NHS providers once a month, from
                                                                                                                                       NHS” makes it clear that patients will be at the heart of      November 2009 to March 2010.
                                                                                                                                       everything that we do. Increasing the collective voice of
                                                                                                                                                                                                      By using CQC Q14 (our Q1) as a baseline, we can
                                                                                                                                       patients and service users is one element of this.
                                                                                                                                                                                                      demonstrate that:
                                                                                                                                       1. Patients will be able to rate services and departments
                                                                                                                                                                                                      • The average regional score of patients who answered
                                                                                                                                          according to the quality of care they received.
                                                                                                                                                                                                        “no” rose from 81% to 92%.
                                                                                                                                       2. There will be an expansion of patient reported outcome
                                                                                                                                                                                                      • One Trust had an overall improvement of 40%
                                                                                                                                          measures and patient data from April 2011.
                                                                                                                                                                                                      • Half the Trusts reported 95% or above on their
                                                                                                                                       3. Local Involvement Networks (LINks) will become
                                                                                                                                                                                                        final score
                                                                                                                                          HealthWatch England, a new consumer champion, from
                                                                                                                                          April 2012.

                                                                                                                                                                                                      CLINICAL JUSTIFICATION
“As part of our work to become as patient-focused as possible, we                                                                                                                                     There are times when the need to treat and admit can
deliberately chose a high-visibility colour for our matrons to wear.                                                                   THREE BENCHMARKED QUESTIONS                                     override the need for complete segregation. This might
Now it is easier for patients and visitors to recognise and approach                                                                                                                                  apply, for instance, with:
them. It is one of the things that has really helped us to change the                                                                  The following questions are currently used by the Care
culture of our organisation.” Diane Wake, Executive Director of Nursing                                                                Quality Commission (CQC) in the annual patient survey. If      • A patient needing high-tech care with one-to-one
and Operations and Director of Infection Prevention and Control at Royal                                                               used consistently, they will provide a useful benchmark from     nursing, e.g. ICU, HDU
Liverpool and Broadgreen University Hospitals NHS Trust.
                                                                                                                                       which to demonstrate improvement.
                                                                                                                                                                                                      • A patient needing very specialised care, where one
                                                                                                                                       CQC Q14: “When you were first admitted to a bed on a             nurse might be caring for a small number of patients
                                                                                                                                       ward, did you share a sleeping area (e.g. a room or a bay)
                                                                                                                                                                                                      • A patient needing very urgent care, e.g. rapid admission
                                                                                                                                       with patients of the opposite sex?”
                                                                                                                                                                                                        following heart attack
   CASE STUDY - USE OF LINKS IN WIRRAL                                     CASE STUDY - PATIENT “ EMPATHY                              CQC Q17: “If you moved to another ward or wards, did you
                                                                                                                                                                                                      Where mixing does occur, it must be justifiable for all the
   UNIVERSITY TEACHING HOSPITALS                                           CARDS” HELP TO COLLECT ACCURATE                             ever share a sleeping area (e.g. a room or a bay) with
                                                                                                                                                                                                      patients affected. There are no blanket exemptions for
                                                                           INFORMATION                                                 patients of the opposite sex?”
   NHS Wirral and Wirral University Hospital NHS Foundation                                                                                                                                           particular specialties, and no exemptions at all from the
                                                                                                                                       CQC Q19: “Whilst staying in hospital, did you ever share       need to provide high standards of privacy and dignity at
   trust have been working in partnership with the Local                   As part of the patient feedback process, staff at Aintree
                                                                                                                                       the same bathroom or shower area as patients of the            all times.
   Involvement Network (LINks) to ensure that the patient                  University Hospital NHS Foundation Trust use “empathy
                                                                                                                                       opposite sex?”
   voice is represented in their improvement work.                         cards” to help them collect accurate information from
                                                                           patients.


                                                                                                                                                                                                                                                                    15
                                                                                                                    5.
CASE STUDY - ELECTRONIC “DASHBOARD”
FOR SAME-SEX ACCOMMODATION
                                                              NHS COMMISSIONERS NEED TO MAKE                                                 ONGOING QUALITY MONITORING AND
Two providers Trusts in the North West are currently          SURE THEY HAVE ASSURANCE, NOT
piloting an electronic “dashboard” to help them               RE-ASSURANCE                                                                   CONTRACT SANCTIONS ARE MANDATED
accurately report and improve on same-sex accommodation.
                                                              Richard Dodds, Project Lead, NHS Standard
If you are interested in trying this in your organisation,
                                                              Contracts, DH.                                    Ongoing quality monitoring is the final step. The routine collection, analysis and reporting of
please contact a member of the team (details on p19).
                                                                                                                breach data will act as a baseline, inform the progress and assure the compliance.
                                                                                                                Commissioners and their providers will undertake this as part of monthly contract monitoring.
                                                              Lockers that open on two sides have enabled       All mixing (breach) data will be discussed as part of clause 8 and clause 33 monthly monitoring,
                                                             effective segregation in the endoscopy unit at     inform the improvement plan and define areas for local action.
                                                                    Burnley, East Lancashire Hospitals Trust.


                                                                                                                 CONTRACT PERFORMANCE MANAGEMENT                                   CASE STUDY - HOTEL-STYLE” RECEPTION
                                                                                                                 & CONSEQUENCES (DH 2010A P95)                                     IN A DEMENTIA ASSESSMENT WARD
                                                                                                                 [See Appendix 5 for a summary of contract                         Cumbria Partnership NHS Foundation Trust has moved a
                                                                                                                 sanctions.]                                                       ward entrance door and created a “hotel-style” reception
                                                                                                                 For same-sex accommodation, consequences will apply for:          area. It has a welcome desk, water dispenser and
                                                                                                                                                                                   comfortable seats. It replaces the old entrance which
                                                                                                                 1. Failure to have a published declaration of compliance
                                                                                                                                                                                   opened immediately onto the ward corridor. Staff feel it
                                                                                                                    / non compliance may be immediate breach when
                                                                                                                     services start and could lead to withholding under 31.1       has delivered additional benefits:

                                                                                                                 2. Failure to have a DSSA plan Breach of the DSSA                 • Improved overall appearance
                                                                                                                    improvement plan may be immediate breach when
                                                                                                                                                                                   • Better privacy to service users and their families
                                                                                                                     services start and could lead to withholding payment
                                                                                                                    under 31.1                                                     • Removal of previous thoroughfare gives better safety

                                                                                                                 3. Failure to meet a milestone in the DSSA improvement            • May also have reduced distress and confusion caused
                                                                                                                    plan could result in use of clause 32 process to have a           by the “high traffic” flow of a busy ward
                                                                                                                    Recovery Action Plan (RAP) and sanction as per local
                                                                                                                    determination if RAP is breached.
                                                                                                                 4. Breach of information requirements could lead to
                                                                                                                    withholding of 2% of the monthly contract value until
                                                                                                                    the required information is provided, leading to retention.
                                                                                                                 5. Non-justified breach of same-sex accommodation could
                                                                                                                    lead to recovery of the cost of the procedure or service
                                                                                                                    received by the patient under clause 7.23, and sanction
                                                                                                                    as per local determination if RAP is breached.
                                                                                                                 Where the breach is not clinically justified, the commissioner
                                                                                                                 is required to enforce the penalties set out in the standard
                                                                                                                 contract (DH 2010f p2). The requirement to deliver same-sex
                                                                                                                 accommodation is covered in the NHS Operating
                                                                                                                 Framework (DH, 2010d), therefore sanctions may apply at
                                                                                                                 all times, including when a contract is still being negotiated.




                                                                                                                                                                                                                                              17
SOLUTIONS BY SPECIALTY


SPECIALTY                  DESCRIPTION                            ORGANISATION                      CONTACT EMAIL ADDRESSES                    SPECIALTY                          DESCRIPTION                             ORGANISATION                     CONTACT EMAIL ADDRESSES

Commissioning             Collaborative working                       NHS Liverpool                  Leigh.thompson@liverpoolpct.nhs.uk        Intensive Care               Improving delayed discharges            East Lancashire NHS Hospital Trust        John.Goodenough@elht.nhs.uk
                      with provider for improvement
                                                                                                                                               Intensive Care                     Same-sex provision                East Lancashire NHS Hospital Trust        John.Goodenough@elht.nhs.uk
Communications       Patient information pack & DVD           5 Boroughs Partnership NHS FT             Joanne.McDonnell@5bp.nhs.uk
Mental Health                                                                                                                                  Learning Disabilities   Daily “women-only” time in the grounds             Calderstones NHS FT                John.smith@calderstones.nhs.uk

Communications           Use of newsletter, task                Manchester Mental Health                                                       Learning Disabilities    Gender-sensitive activities programme.            Calderstones NHS FT                John.smith@calderstones.nhs.uk
Mental Health                & finish group                      & Social Care NHS Trust                 Sheila.Kasavan@mhsc.nhs.uk
                                                                                                                                               Medical assessment                      Redesign                  Warrington & Halton Hospitals NHS Trust        Michele.lord@whh.nhs.uk
Coronary Care             Single room provision             Aintree University Hospitals NHS FT           Gail.hewitt@aintree.nhs.uk
                                                                                                                                               Medicine:                 Integration of specialties to support             Central Manchester                   Fiona.geiger@cmft.nhs.uk
Day surgery         Redesign using existing footprint.    North Cumbria Acute Hospitals NHS FT      Richard.Heaton@ncumbria-acute.nhs.uk       Acute medical                       same-sex wards.                     University Hospitals NHS FT
                           Staff involvement.                                                                                                  Diabetology
                    Work carried out at weekends to                                                                                            Respiratory
                      minimise theatre disruption.                                                                                             Gastroenterology

Day surgery           Colour coded theatre template                 Stockport NHS FT                     Nicola.firth@stockport.nhs.uk         Mental Health              Hotel-style reception in Dementia            Cumbria Partnership NHS FT              Pat.dobson@cumbria.nhs.uk
                                                                                                                                                                                  assessment ward
Demand & capacity         IT Information System             East Lancashire Hospitals NHS Trust         John.Goodenough@elht.nhs.uk
Flow management                                                                                                                                Mental Health             Separation of services along gender             Lancashire Care NHS FT            Gary.chadwick@lancashirecare.nhs.uk
                                                                                                                                                                          lines in Psychiatric Intensive Care
Discharge lounge      Partnership with a charity to              Pennine Acute NHS Trust               Victor.crumbleholme@pat.nhs.uk
                      provide clothes for discharge                                                                                            Ophthalmology                           New area                  Warrington & Halton Hospitals NHS Trust        Michele.lord@whh.nhs.uk

Emergency                Same-sex waiting area               Royal Liverpool and Broadgreen               Sue.redfern@rlbuht.nhs.uk            Patient feedback                Use of “empathy cards”              Aintree University Hospitals NHS FT         Gail.hewitt@aintree.nhs.uk
Department                                                    University Hospitals NHS Trust
                                                                                                                                               Patient involvement          Use of “discovery interviews”            Mid Cheshire Hospitals NHS FT            Philippa.Pordes@mcht.nhs.uk
Endoscopy                     Same-sex lists                    Stockport Foundation Trust              Nicola.Firth@stockport.nhs.uk
                                                                                                                                               Patient involvement       Use of Local Involvement Networks
Endoscopy                       New unit                 Warrington & Halton Hospitals NHS Trust          Michele.lord@whh.nhs.uk                                             (LINks) to support DSSA               Wirral University Hospital NHS FT            Lesley.metcalf@nhs.net

Estates              Effective procurement kept costs    Blackpool, Fylde & Wyre Hospitals NHS FT   Jonathan.Campbell@bfwhospitals.nhs.uk      Surgical Assessment              Same-sex waiting area                Royal Liverpool and Broadgreen             Sue.redfern@rlbuht.nhs.uk
                            down & quality high                                                                                                   unit                                                                University Hospitals NHS Trust

Estates              Demountable panels in day case       Lancashire Teaching Hospitals NHS FT           Stephen.Obrien@lthtr.nhs.uk        Surgical Assessment unit              No breach in 6yrs                Aintree University Hospitals NHS FT         Gail.hewitt@aintree.nhs.uk
                        as shorter term solution
                                                                                                                                               Training                     Training for all staff, including        Royal Liverpool and Broadgreen             Sue.redfern@rlbuht.nhs.uk
Estates              Scoping exercise & audit sheets           Countess of Chester NHS FT                Steve.deveney@coch.nhs.uk                                                    contractors                     University Hospitals NHS Trust

Estates Patient       Direct use of patient feedback           Countess of Chester NHS FT                Steve.deveney@coch.nhs.uk             Transsexual care             Trust commended by patient.          Lancashire Teaching Hospitals NHS Trust       Stephen.Obrien@lthtr.nhs.uk
involvement                                                                                                                                                                      Navajo charter mark.
                                                                                                                                                                              www.navajoonline.org.uk
Gastroenterology                Redesign                     Royal Liverpool and Broadgreen               Sue.redfern@rlbuht.nhs.uk
                                                              University Hospitals NHS Trust

Governance             Auditable Trust compliance            Royal Liverpool and Broadgreen               Sue.redfern@rlbuht.nhs.uk
                          standard for DSSA                   University Hospitals NHS Trust

Governance           Pilot of an electronic reporting    Walton Centre NHS Foundation Trust and       Lisa.grant@thewaltoncentre.nhs.uk
                           dashboard for DSSA            Southport & Ormskirk Hospital NHS Trust

Governance          Use of daily cross to monitor DSSA         Countess of Chester NHS FT                 gaynor.hales@coch.nhs.uk



                                                                                                                                                                                                                                                                                                 19
FURTHER SUPPORT - ESTATES


Estate solutions                                                                                                                     Same-sex accommodation project contacts & support
Any new builds or major capital refurbishments must comply with the DH Health Building                                               The North West Lead for same-sex accommodation is:

Notes and Health Technical Memoranda. Commissioners should be satisfied that same-sex
accommodation is assured for any scheme proposals during the planning stages. We advise
that plans are pro-actively scrutinised by all stakeholders, with particular attention to the
movement of patients and potential “cross-flow” issues, including the placement of toilets                                                                                                              I LIKE THE LAYOUT OF THE NEW UNIT;
and bathrooms.                                                                                                                                                                                          IT HAS BEEN DESIGNED FOR PATIENT
                                                                                                                                                                                                        PRIVACY, WHICH IS IMPORTANT WHEN
In the North West, we have three sub-regional Strategic Estates Leads who are happy to support and advise on any proposed
developments.
                                                                                                                                                                                                        COMING ROUND FROM THE GENERAL
                                                                                                                                                                                                        ANAESTHETIC
                                                                                                                                                                                                        Ophthalmology patient, Warrington.




                                                                                                                                     Julie Clark
                                                                                                                                     Assistant Director of Performance.
                                                                                                                                     julie.clark@northwest.nhs.uk




                                                                                                                                     The North West was unique in appointing three sub-regional leads to support this agenda. They remain in post throughout 2010.

                                                                                                                                     Please do not hesitate to get in touch with any of the team if you need advice or support.


CHESHIRE & MERSEYSIDE:                         CUMBRIA & LANCASHIRE:                          GREATER MANCHESTER:
Nigel Dunstan                                  Andy Pratt                                     Carrie Berry
nigel.dunstan@shaest-n.nhs.uk                  andy.pratt@shaest-n.nhs.uk                     carolyn.berry@shaest-n.nhs.uk



DESIGN COUNCIL INNOVATIONS
In partnership with the Department of Health, the Design Council has spearheaded the development of a range of products under
the Design for Dignity campaign.
Details can be viewed at: www.designcouncil.org.uk/our-world/challenges/Health/Design-for-Patient-Dignity/



                                                                                                                                     CHESHIRE & MERSEYSIDE:                        CUMBRIA & LANCASHIRE:                          GREATER MANCHESTER:
                                                                                                                                     Karen Abinett                                 Julia Charnock                                 Sandra Walker (nee Ward)
                                                                           CASE STUDY - USE YOUR FLOOR PLANS                         karen.abinett@sefton.nhs.uk                   julia.charnock@centrallancashire.nhs.uk        sandra.ward4@nhs.net
                                                                           TO ELIMINATE “CROSS FLOW”
                                                                           Use coloured pens on a copy of your floor plan to
                                                                           indicate the male / female areas, and the related flows
                                                                           of patients to toilets, bathrooms and treatment areas.




                                                                                                                                                                                                                                                                     21
  SAME-SEX ACCOMMODATION CONTACT LIST
  The following people have indicated that they are happy to be a point of contact for same-sex accommodation in their organisation.
  See also “Solutions by speciality” on p18.
                                                                                                                                           Links to key documents
    NAME                              ORGANISATION                                              EMAIL                        TEL NO.       Department of Health documents relating to the same-sex accommodation project are
                                                                                                                                           now being hosted by the NHS Institute for Innovation and Improvement. The Productive
  Paul Carroll                   NHS Ashton, Leigh and Wigan                           paul.carroll@alwpct.nhs.uk          01942 482 833   Series also includes a new supplement; “Privacy, Dignity and Same-Sex Accommodation”
                                                                                                                                           http://www.institute.nhs.uk/
  Anne Asher                      NHS Blackburn with Darwen                           anne.asher@bwdpct.nhs.uk             01254 282 042

 Helen Skerritt                          NHS Blackpool                              helen.skerritt@blackpool.nhs.uk        01253 651 269   A collection of the main DH documents and supporting NHS North West products and
  Helen Clarke                            NHS Bolton                                  helen.clarke@bolton.nhs.uk           01204 462 322
                                                                                                                                           documents can be downloaded at: http://nww.northwest.nhs.uk/PrivacyandDignity/

 Glenn Mather                       NHS Central Lancashire                       glenn.mather@centrallancashire.nhs.uk     01772 643 111

Yvonne Lochhead                NHS Central and Eastern Cheshire                     yvonne.lochhead@cecpct.nhs.uk          07887 804 542
                                                                                                                                           CURRENT DOCUMENTS:
                                                                                                                                           KEY DOCUMENTS                              MANAGEMENT GUIDANCE (DH):
 Seamus McGirr                     NHS Halton and St Helens                          seamus.mcgirr@hsthpct.nhs.uk          0151 495 5176
                                                                                                                                           DSSA principles version 2 (DH)             • Board leadership
 Nicola Crosby              NHS Heywood, Middleton and Rochdale                        nicola.crosby@hmr.nhs.uk            01706 652 808
                                                                                                                                           Policy & procedure template (NHS NW)       • Buildings & facilities
Leigh Thompson                           NHS Liverpool                              leigh.thompson@liverpool.nhs.uk        0151 296 7683
                                                                                                                                           DSSA Plan template (NHS NW)                • Capacity & demand
   Sue Mundy                            NHS Manchester                               sue.mundy@manchester.nhs.uk           0161 765 4363
                                                                                                                                           Breach guidance (NHS NW)                   • Commissioning
  Gary O'Neill                       NHS North Lancashire                            gary.o'neill@northlancs.nhs.uk        01524 519325
                                                                                                                                           DSSA status report (NHS NW)                • Q&A for commissioners
 Tanya Claridge                        NHS Oldham PCT                                   tanya.claridge@nhs.net             0161 622 4334
                                                                                                                                           Reporting template (NHS NW)                • Communications
   Toni Doyle                             NHS Salford                                  toni.doyle@salford.nhs.uk           0161 212 4843
                                                                                                                                           E-bulletin library (NHS NW)                • Governance & assurance
  Sue Williams                            NHS Sefton                                  sue.williams@sefton.nhs.uk           0151 247 7220
                                                                                                                                                                                      • Patient experience
    Tim Ryley                            NHS Stockport                               tim.ryley@stockport-pct.nhs.uk        0161 426 5573
                                                                                                                                           SERVICE-SPECIFIC GUIDANCE (DH):
 Louise Roberts                    NHS Tameside and Glossop                              louise.roberts@nhs.net            0161 335 2908
                                                                                                                                           • Assessment units                         COMMUNICATIONS RESOURCES (NHS NW)
 Jason Hughes                             NHS Trafford                               Jason.hughes@trafford.nhs.uk          0161 873 6091
                                                                                                                                           • Critical care                            • A4 poster – patients
Lorraine Jackman                     NHS Western Cheshire                        lorraine.jackman@wcheshirepct.nhs.uk      01244 650 360
                                                                                                                                           • Children & young people                  • A4 poster – staff
   Val Tarbath                             NHS Wirral                                  val.tarbath@wirral.nhs.uk           0151 651 0011                                              • A4 patient leaflet
                                                                                                                                           • Day surgery
                                                                                                                                           • Endoscopy                                • Bookmark
  Cheryl Swan       Blackpool Fylde and Wyre Hospitals NHS Foundation Trust        cheryl.swan@bfwhospitals.nhs.uk         01253 655 632   • Elective pathway                         • Image- web gadget
 Avril Devaney       Cheshire and Wirral Partnership NHS Foundation Trust              avril.devaney@cwp.nhs.uk            01244 397 373   • Renal care
 Gaynor Hales          Countess of Chester Hospital NHS Foundation Trust               gaynor.hales@coch.nhs.uk            01244 365 291   • Young adults
  Pat Dobson               Cumbria Partnership NHS Foundation Trust                   Pat.Dobson@cumbria.nhs.uk            01228 603 992   • Mental health & learning disabilities
  Sandy Brown             North Cumbria University Hospitals NHS Trust                 sandy.brown@ncuh.nhs.uk             01946 523 072

Hayley Reading                 East Cheshire Hospitals NHS Trust                hayley.reading@echeshire-tr.nwest.nhs.uk   01625 661 780

 Patrick Sullivan            Lancashire Care NHS Foundation Trust                patrick.sullivan@lancashirecare.nhs.uk    01772 695 360

  Diane Wake        Royal Liverpool and Broadgreen University Hospitals Trust          diane.wake@rlbuht.nhs.uk            0151 706 2231

Ann Birmingham               NHS Sefton Community Health Services                   ann.birmingham@sefton.nhs.uk           0151 247 6243

  Anne Hyson          St Helens and Knowsley Teaching Hospitals NHS Trust               anne.hyson@sthk.nhs.uk             0151 426 1600

 Lesley Metcalfe    Wirral University Teaching Hospitals NHS Foundation Trust           lesley.metcalfe@nhs.net            0151 678 5111

                                                                                                                                                                                                                                  23
                                                                                                                         APPENDIX 2
                                                                                                                         DH compliance checklist
    APPENDICES
                                                                                                                          PATIENT EXPERIENCE                                                                  EVIDENCE

APPENDIX 1                                                                                                                1. Patient experience of SSA has been measured on three separate                    Submitted information to SHAs/PCTs
                                                                                                                          occasions to demonstrate progress and submitted to SHA as requested
North West Regional outputs 2009/10
                                                                                                                          2. There is an on-going process in place to continue to measure                     Results of patient experience surveys
Schemes supported by the Challenge Fund for the elimination                                                                patient experience of SSA with reports to be submitted to the Board                Timescales for improvement Reports to the Board
of mixed-sex accommodation were completed.                                                                                                                                                                    Delivery Plan
                                                                                                                          3. There is a process to track other mechanisms for determining                     Operational plans
Scheme outputs included:
                                                                                                                          patient experience of DSSA, e.g. through patient complaints/comments,               Reports to the Board
•   268 toilets, bathrooms and washrooms                                                                                  PALs, LinKs                                                                         Delivery Plan
•   214 new hard screens or partitions
                                                                                                                          4. Information leaflets for patients on DSSA are available and                      Patient experience surveys, Leaflets/posters
•   653 curtains                                                                                                           used by staff in discussions.                                                      Communication to patients
•   33 matrons
                                                                                                                          ESTATES
20 Peer Improvement reviews were completed in NHS                                                                         5. P&D fund allocation spent and projects completed                                 Report to SHA & PCTs
provider organisations.                                                                                                   6. Estate able to support virtual elimination of MSA                                Estates Survey

Sharing and learning events were held for providers and                                                                   7. Delivery of SSA is assured in planning of any new or                             Trust DSSA Policy
commissioners during 2009-2010.                                                                                           refurbished capital development schemes                                             Reports to the Board
                                                                                                                                                                                                              Delivery Plan
All NHS provider trusts completed and published declarations    CASE STUDY - PATIENTS DITCH                               SYSTEMS & PROCESSES
of compliance to delivering same-sex accommodation.             THE PYJAMAS                                               8. Assurance to the Board and monthly PCT reporting including a system              Reports to the Board
                                                                                                                          of tracking all occurrences of mixing, whether clinically justified or not          Included in dashboard
Patient experience data were collected on five occasions and    Several NHS provider Trusts are actively encouraging                                                                                          Policy/procedure in place
this shows 11% improvement from regional baseline.              patients to wear their own clothes whilst in hospital.                                                                                        Providers report
                                                                                                                                                                                                              Delivery Plan
Regional communications support and exclusive products          This begins with the pre-admission information and is
                                                                supported at various points in the patient pathway.       9. Where the are rare occurrences for non-clinical reasons, a process
were made available:
                                                                                                                          exists to investigate reason, take prompt action and take remedial                  Delivery Plan
•   A regular e-bulletin to subscribers                                                                                   actions as required to prevent future occurrence                                    Process e.g. MSA, Root Cause Analysis in place, used by staff

•   A regional brand – posters, patient information leaflets,                                                             10. Relevant Trust policies refer to requirement to DSSA and privacy and dignity    Policies
    banners                                                                                                                                                                                                   Delivery Plan
•   Packs for provider Trusts to host Awareness Weeks                                                                     11. The Trust can demonstrate the virtual elimination of MSA in:                    Reports showing virtually no occurrences in these areas
                                                                                                                              Wards                                                                           Delivery Plan
New regional management tools were developed, based on                                                                        AssessmentUnits
latest policy:                                                                                                                Day facilities
•   A policy and procedure template                                                                                       Patients do not share sleeping accommodation or toilet facilities with members
•   A template to guide the DSSA plan                                                                                     of opposite sex
•   Regional guidance on breach definition
                                                                                                                          STAFF CULTURE
•   A self-assessment process for PCOs                                                                                    12. The Board demonstrates a commitment to on-going delivery of SSA                 Stated in Board reports
•   A pack to support the peer review process                                                                                                                                                                 Declaration on website
•   Suggested insertions for NHS standard contract quality                                                                                                                                                    Delivery Plan
    schedules                                                                                                             13. The Trust has articulated its intent to deliver care with privacy and dignity   Articulated within strategic goals, business plan, on website
                                                                                                                          within which delivering same-sex accommodation is an integral component             Delivery Plan
The documents are available from the team (contact details
                                                                                                                                                                                                              Included in staff induction training
on p19) or can be downloaded at:
http://nww.northwest.nhs.uk/PrivacyandDignity/                                                                            14. The Trust believes that delivering SSA should be the norm. Mixing will only     Evidence of language that mix sex accommodation is the
                                                                                                                          occur by exception for reasons of clinical justification or patient choice          rare exception and not a normal occurrence
3 unique posts were developed – sub-regional DSSA leads                                                                                                                                                       Delivery Plan
hosted by PCTs (see p19)                                                                                                  15. If mixing does occur, staff attempt to rectify the situation as soon as         Rectification actions and good communication around
                                                                                                                          possible, whilst safeguarding the individuals dignity and keeping the patient       same-sex occurrences are demonstrated in local feed
                                                                                                                          informed about; why the situation occurred and what is being done to address it     back mechanisms (eg RCA, discharge questionnaires).
                                                                                                                          (with indication of timescales)                                                     Paragraph on remedial action included in policy

                                                                                                                                                                                                                                                                              25
  APPENDIX 3                                                                                                                                                       APPENDIX 4
  Contract performance flow chart (DH, 2010a p95.)                                                                                                                 Key contract provisions                                              What this means
                                                                                                                                                                   CLAUSE 4.24 AND 4.25                                                 PART 1 – SELF DECLARATION AND DSSA PLAN
                               Clinical or Service Quality
 Enact any consequence                                                                           Material failure to meet
                                  Performance Report              Review in accordance
  set out in Schedule 3                                                                            requirements of              General Contract Query                                                                                  •   At 31 March 2010 all providers who fall within the definitions
                                  (clause 33) identifies                  with                                                                                     4.24      Where appropriate to the Services Environment the
 (Clause 31.5 or Clause                                                                               Agreement                     Clause 32.3
                                    clinical or service                 Clause 8                                                                                                                                                            in the DH guidance had to declare and publish their status
          7.26)                                                                                     Clause 32.4.5                                                            Provider shall have a DSSA Plan, shall comply with the
                                   performance issue
                                                                                                                                                                             obligations in that plan and shall report any breach of        on their web page
                                                                                                                                                                             the DSSA Plan in accordance with to the Co-ordinating      •   Providers had to have a DSSA Plan (see definition)
                                        Follow SUI
                                       investigation                                                                                                                         Commissioner.
                                         process                                                                                                                                                                                        •   A failure to have the published statement meant that the
                                                                     Performance Notice
                                                                                                                                                                   4.25      The Provider shall undertake a self assessment of the          provider could not (theoretically) deliver services
                                                                                                                                                                             delivery of Services from the perspective of Patient
                                                                                                                                                                                                                                        •   Failure to have the DSSA Plan would be a breach of contract
                                                                                Clause 32.8                                                                                  experience, culture, equality, human rights, estates
                                 Never Events reported                                                                                                                                                                                      and would allow the commissioners to take action under
                                 under SUI provisions                                                                                                                        and systems and procedures and, with reference to
                                                                                                                                                                                                                                            the contract either to make an immediate deduction
                                                                                                                                                                             that self assessment, the Provider and the Co-ordinating
                                                                                                                                                                                                                                            (clause 31- Breach of National Standard) or performance
                                                             Clause 32.10                                                                                                    Commissioner shall include in the DSSA Plan the
                                      Meet to discuss                                                                                                                                                                                       mange the provider under clause 29 – information
                                                                                      Clause 32.9
                                    Performance Notice       No                                                                  Remedial                                    milestones to be achieved by the Provider during the
                                                                                                                                                                                                                                            requirements and clause 32 – performance management
                                    within 10 operational             Excusing Notice?                 Close                    Action Plan                                  Contract Year.     Each of those milestones will be
                                    days of Performance                                   Yes                                  Implemented?           No                                                                                    process
                                          Notice                                                                        Yes                                                  reviewed as part of the monthly review process
                                                                                                                                                                             referred to in clause 8 (Review).                          •   The breach of Information requirements could result in
Clause 32.11.1                                                                                                                                                                                                                              the withholding of 1% contract value until the information
                                                                                                                                                                   PAYMENTS                                                                 is provided, after which the withheld sum is returned. If
                                                                                          Clause 32.19                          Review
          Agree Joint          No      Clause 32.11.2                                                                   progress against plan on                                                                                            the information remained outstanding then the 1% can
         Investigation                                                                                                                                             7.23      The Provider shall repay to the relevant Commissioner
                                                                                                                        monthly basis (clause 8)
                                                                                                                                                                                                                                            be retained by the commissioner
                                                                                                                                                                             or the relevant Commissioner shall not pay the
          Yes     Clause 32.12                                                                                                                                               Provider (as appropriate), the relevant sums set out in    •   Under the performance management clause, the provider
                                                                                          Yes                                                                                Schedule 3 Part 4B (Nationally Specified Events) (as
                                                                                                                Clause 32.23                                                                                                                is taken through a process based on action planning which
                                                                     Clause 32.16
         Conduct Joint                          Agree a                                                                                                                      may be amended from time to time by Guidance) for
                                                                                                                 No            Remedial                                                                                                     could lead to a sum of up to 2% of the contract value
       Investigation and                    Remedial Action                     Remedial Action
     provisional action plan               Plan within 5 days                                                           Action Plan breached not                             any Service or part of a Service in relation to which a        being withheld if the action plan is breached. The withheld
                                                                                 Plan Agreed?
       where appropriate                                                                                                   remedied in 5 days
                                                                                                                                                                             Nationally Specified Event Threshold has been                  sum can be retained if the provider fails to take action and
                                                                                    No                                                                                       breached. Further, the Provider shall pay any additional       the provider’s board have been put on notice and that
                                                                                                                                          Yes
                                                                        Clause 32.21                                  Clause 32.23                                           payment relating to any Nationally Specified Event             notice has been copied to CQC, SHA and if appropriate
              Joint
                                                                           Withhold up to 10% of the                                                                         that is introduced by Guidance.                                Monitor
          Investigation         No                                          monthly contract value                          Issue 1st Exception
          Recommends
                                     Clause 32.14.2                         until plan agreed, Once                               Report
       Performance Notice
                                                                           agreed, the withheld sum
            Closed?
                                                                                   is returned
                                                                                                                                                                   SCHEDULE 3 PART 4B
          Yes
 Clause 32.14.1
                                                                                                                                                                            NATIONALLY                       THRESHOLD             METHOD OF                                CONSEQUENCE
                                                                            Withhold up to 2% of
                                                                            monthly sums for each                                                       Return              SPECIFIED EVENT                                       MEASUREMENT                                PER BREACH
                                                                                                                      Clause 32.25                      withheld
                                                                             milestone not met in
                                                                            Remedial Action Plan                                                        amount              Breach of the Same-Sex                  >0         Review of Monthly Clinical          Recovery of the cost of the procedure
                                                                                 up to 10%                                                                                  Accommodation Requirements                         Quality Performance Report            or service received by the Patient
             Close                                                                                                                              Clause 32.26
                                                                                                                                                                   SCHEDULE 3 PART 4                                                    PART 2 – MIXING OF SEXES ON A DAY TO DAY BASIS
                                                                                                                                                      Yes
                                                                                                                            Remedial Action Plan
                                                                                                                                remedied?                          •   A declaration from the Provider regarding whether or not         •   As part of the monthly contract review process (clause 8)
                                                                                                                                                                       it    complies    with    the     Same-Sex    Accommodation          the provider should alert the commissioner to ANY mixing
                                                                       Second Exception Report issued
                                                                                                                                No                                     Requirements                                                         of sexes that has occurred in the month
                          Appropriate                                  to the boards of the Provider and
                                                      Clause 32.24                                              Clause 32.24
                         action agreed                                  Commissioner and to the SHA,
                         by the parties                                                                                                                            •   The DSSA Plan                                                    •   The commissioner and provider would agree which of the
                                                                         Regulator and if applicable to
                                                                                   Monitor                                                                                                                                                  occurrences where clinically justified – no action would be
                                                                                                                                                                                                                                            taken on these
                                                                         Clause 32.27
                                                                                                                      Key:
                                                                                                                                                                                                                                        •   For non-clinically justified occurrences the provider would
                                                                                                                                 = 1st Stage                                                                                                deduct (clause 7.23) the sum equivalent to the cost of the
                                                                            Permanently retain
                                                                             withheld amount                                     =2  nd
                                                                                                                                          Stage                                                                                             procedure or service received by all patient affected by
                                                                                                                                                                                                                                            the breach
                                                                                                                                 = 3rd Stage
                                                                                                                                                                                                                                                                                                             27
                                                                  REQUIREMENTS MET?
                     ACCOMMODATION




                                                                  ACCOMMODATION
APPENDIX 5




                                     PLAN AGREED?
                                     IMPROVEMENT

                                                    IMPROVEMENT
                     ELIMINATED”?
Contract




                     “VIRTUALLY




                                                    PLAN MET?
                     MIXED-SEX




                                                                  SAME-SEX
Sanctions
                                                                                      OUTCOME
Matrix
(DH 2010c annex 5;   YES              YES YES                       YES               Normal business. Clause 8 & clause 33 monthly monitoring
DH 2010a)            YES              YES X                         YES               • Clause 32 process followed to have Remedial Action Plan (RAP)
                                                                                      • Sanction as per local determination if RAP breached
                     YES              YES YES                       X                 • Recovery of cost of the procedure or service received by the patient under clause 7.23
                                                                                      • Clause 32 process to follow up breach to have a RAP
                                                                                      • Sanction as per local determination if RAP breached
                     YES              X             n/a             YES               • If the pre-contract requirement is waived by PCT, then provider in immediate breach
                                                                                        when services start and a withholding possible under 31.1
                                                                                      • Sanction as per local determination
                     YES              X             n/a             X                 • If the pre-contract requirement is waived by PCT, then provider in immediate breach
                                                                                        when services start and a withholding possible under 31.1
                                                                                      • Recovery of cost of the procedure or service received by the patient under clause 7.23
                     X                YES YES                       YES               • If the pre-contract requirement is waived by PCT, then provider in immediate breach
                                                                                        when services start and a withholding possible under 31.1
                     X                YES X                         YES               • If the pre-contract requirement is waived by PCT, then provider in immediate breach
                                                                                       when services start and a withholding possible under 31.1
                                                                                      • Sanction as per local determination.
                     X                YES YES                       X                 • If the pre-contract requirement is waived by PCT, then provider in immediate breach
                                                                                       when services start and a withholding possible under 31.1
                                                                                      • Recovery of cost of the procedure or service received by the patient under clause 7.23
                     X                X             n/a             YES               • If the pre-contract requirement is waived by PCT, then provider in immediate breach
                                                                                       when services start and a withholding possible under 31.1
                                                                                      • Sanction as per local determination.
                     X                X             n/a             X                 • If the pre-contract requirement is waived by PCT, then provider in immediate breach
                                                                                        when services start and a withholding possible under 31.1
                                                                                      • Sanction as per local determination.
                                                                                      • Recovery of cost of the procedure or service received by the patient under clause 7.23
                     Not      YES YES                               YES               • If the pre-contract requirement is waived by PCT, then provider in immediate breach
                     provided                                                           when services start and a withholding possible under 31.1
                                                                                      • Withholding of 2% of the monthly contract value until the required information is
                                                                                        provided, leading to retention
                     Not      YES X                                 YES               • If the pre-contract requirement is waived by PCT, then provider in immediate
                     provided                                                           breach when services start and a withholding possible under 31.1
                                                                                      • Withholding of 2% of the monthly contract value until the required information is
                                                                                        provided, leading to retention.
                                                                                      • Clause 32 process followed to have a RAP. Sanction as per local determination if
                                                                                        RAP breached
                     Not      YES YES                               X                 • If the pre-contract requirement is waived by PCT, then provider in immediate breach      A single en-suite room at Cumbria
                                                                                                                                                                                 Partnership NHS Foundation Trust. The
                     provided                                                          when services start and a withholding possible under 31.1
                                                                                                                                                                                 privacy screen handle is on the inside of the
                                                                                      • Withholding of 2% of the monthly contract value until the required information is        door so that the service user can control it.
                                                                                        provided, leading to retention.
                                                                                      • Recovery of cost of the procedure or service received by the patient under clause 7.23
                     Not      X                     n/a             YES               • If the pre-contract requirement is waived by PCT, then provider in immediate breach
                     provided                                                          when services start and a withholding possible under 31.1
                                                                                      • Withholding of 2% of the monthly contract value until the required information is
                                                                                        provided, leading to retention
                     Not      X                     n/a             n/a               • If the pre-contract requirement is waived by PCT, then provider in immediate breach
                     provided                                                           when services start and a withholding possible under 31.1
                                                                                      • Withholding of 2% of the monthly contract value until the required information is
                                                                                        provided, leading to retention
                                                                                                                                                                                                                                 29
REFERENCES
Copies of most documents are available from:

http://www.institute.nhs.uk/delivering_same_sex_accommodation/delivering_same_sex_accommodation/delivering_
same_sex_accommodation.html

CARE QUALITY COMMISSION (2010A) National patient survey 2009 CQC, London

CARE QUALITY COMMISSION (2010B) Guidance about compliance: Essential standards of quality & safety CQC, London

DH (2007) Privacy & Dignity – A report by the Chief Nursing Officer into mixed sex accommodation in hospitals DH, London

DH (2009a) CNO letter – Eliminating Mixed-Sex accommodation DH, London

DH (2009b) Delivering same-sex accommodation – principles DH. London

DH (2009c) Delivering Same-Sex Accommodation in Mental Health and Learning Disabilities DH, London

DH (2009d) The Operating Framework for the NHS in England 2010/2011 DH, London

DH (2009e) The Story So Far: Delivering Same-Sex Accommodation – A Progress Report December 2009 DH, London

DH (2010a) Guidance on the NHS standard contract for Acute Hospital Services 2010/2011 DH, London

DH (2010b) The NHS Standard Contract for Acute Hospital Services 2010/2011 DH, London

DH (2010c) Letter – Delivering Same-Sex Accommodation – Self-Declaration Gateway ref: 13530, DH, London

DH (2010d) Revision to the Operating framework for the NHS in England 2010/2011 DH, London

DH (2010e) DSSA principles Ver 2.0 DH, London

DH (2010f) DSSA questions & answers for PCT commissioners DH, London

DH (2010g) White paper Equality and Excellence: Liberating the NHS DH, London

DH / NPSA (2009) Action on mixed-sex accommodation root cause analysis tool Gateway ref: 11872 Department of Health, London
                                                                                                                              Staff at Royal Oldham Hospital, part of Pennine Acute
                                                                                                                              Hospitals Trust, identified that several of their patients,
                                                                                                                              many of whom were elderly or infirm, were unable to
                                                                                                                              obtain their own clothes prior to going home. The
                                                                                                                              hospital now works in partnership with a local charity
                                                                                                                              to provide good quality, clean clothes as an alternative
                                                                                                                              to people having to travel home in nightwear.




                                                                                                                                                                                   THANK YOU TO ALL THE ORGANISATIONS WHO SUBMITTED
                                                                                                                                                                                       CASE STUDIES, INVITED TEAM MEMBERS TO VISIT AND
                                                                                                                                                                                             OPENED THEIR DOORS FOR THE PHOTO-SHOOT.
                                                          WHEN WE LOOKED AT OUR
                                                                                                                                                                   Thank you to Sheila Lloyd, former Assistant Director of Nursing, Quality and Performance
                                                          ACCOMMODATION IN INTENSIVE
                                                                                                                                                                                               at NHS North West; who led the programme until October 2009.
                                                          CARE, WE REALISED THAT WE DID                                                                                                     The advice and assistance of Angela Hamilton, Associate Director of
                                                          NOT NEED TO PUT MALES AND                                                                                       Patient Experience and Engagement, NHS Yorkshire & Humber and Richard Dodds,
                                                          FEMALES TOGETHER                                                                                                 Project Lead, NHS Standard Contracts, Department of Health is much appreciated.

                                                          Senior manager, North Cumbria Acute                                                                                                                         EDITORIAL TEAM: Julie Clark, Lucy Jones.
                                                          NHS Foundation Trust.
                                                                                                                                                                                                                      PHOTOGRAPHY: Jason Lock Photography.

                                                                                                                                                                                                                                          DESIGN: Jo Hadfield.

                                                                                                                                                                                                                                                                  31

								
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