Action Plan for Mixed Sex Accomo

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					                                                                                                                                                      Whipps Cross University Hospital
                                                                                                                                                                                              NHS Trust

                                                   Mixed Sex Accommodation – Update for NHS London

The Trust continues to strive to ensure patients privacy and dignity is maintained. We now have the majority of our wards identified as having single sex
sleeping accommodation. This includes most of our nightingale style wards and all of our newer wards in Phase 1 and 2, which have 4 to 6 bed bays.

                                                     Audit Checklist – Trust results July 2008
Objective 1 - to ensure that appropriate organisational arrangements are in place to secure good standards of privacy and dignity for hospital

                                                                                                                               Details of non compliance                                  Relates to
                                Statement                                            Compliance
                                                                                                                                                                                         objective on
                                                                                                                                                                                         action plan
                                                                                                                    Acorn (Paediatric - elective and emergency)                               1
    Elective patients are accommodated in single rooms,                                No
    single sex wards or single sex bays/rooms within
                                                                                                          Elizabeth (Cardiology and CCU - elective and emergency)                             2
    mixed wards.
                                                                                                                             ICU (elective and emergency)                                     3

                                                                                      Yes                                    Areas of Compliance
                                                                                                               Poplar, Primrose, Rowan, Sage, Sycamore, Syringa

                                                                                                                        Blackthorn (Elderly Care - emergency)                                 4
    Nightingale1 wards accommodate either men or                                       No
                                                                                                                         Chestnut Elderly Care (emergency)
    women, but not both.
                                                                                                                         Curie (Acute Medicine - emergency)
                                                                                                                          Wavell (Stroke Unit - emergency)

                                                                                                           Elizabeth (Cardiology and CCU - elective & emergency)                              2
                                                                                                          EMC bay B (Level 2 area Medical Emergency Admissions)                               3
                                                                                                                         ICU (elective & emergency)

    Any large, open-plan space, which has not been subdivided into bays or cubicles, and which offers dormitory-style accommodation for 12 or more patients
                                                         Yes                    Areas of Compliance
                                                                               Acacia (infection control)
                                                               Beech, Birch, Bracken, Conifer (elderly care - emergency)
                                                                  Centenary, EMC - all areas except B bay (medicine
                                                                                   admission units)
                                                               Nightingale, Faraday (respiratory medicine – emergency)
                                                                             Peace / Victory (rehabilitation)

                                                                                         Acorn                             1
Patients admitted as an emergency are                    No
accommodated in single rooms, single-sex wards or
                                                                            Elizabeth (Cardiology and CCU                  2
single-sex bays/rooms. Where the use of mixed-sex
accommodation is unavoidable, the patient is moved
                                                               EMC bay B (Level 2 area Medical Emergency Admissions)       3
to single-sex accommodation within 24 hours of their
                                                                           ICU (elective and emergency)
                                                                                Areas of Compliance
                                                                               Acacia (infection control)
                                                               Beech, Birch, Bracken, Conifer (elderly care - emergency)
                                                                  Centenary, EMC - all areas except B bay (medicine
                                                                                   admission units)
                                                               Nightingale, Faraday (respiratory medicine – emergency)
                                                                             Peace / Victory (rehabilitation)
                                                                 Poplar, Primrose, Rowan, Sage, Sycamore, Syringa
                                                                      (Acute surgery - elective and emergency )

                                                                 Trust Monitoring for areas of compliance and non
                                                                        compliance is detailed in action 7
Except in an emergency, patients are told in writing     No      The Trust does not give written information to elective   5
prior to admission if any parts of the ward are shared            admission patients covering shared accommodation
between men and women.

Patients know that they may request alternative          No              To be developed for elective surgery              5
accommodation, or refuse admission, where
accommodation offered is shared by men and
women. If they refuse admission, you offer a further
admission date within one month of the original date.

Patients are given privacy during treatment,             Yes
consultation, or when receiving personal care

Personal conversations with patients are conducted       No    Ward rounds are conducted at the patients bedside in all      6
away from the bedside or in such a way that cannot                               areas of the trust
be overheard by other patients and/or visitors.
                                                                  Breaking bad news is occasionally conducted at the
Conversations with visitors are conducted away from
                                                               patients bedside because of the patients clinical condition
the bedside in a private room or area.

                                                                                Areas of Compliance
                                                               Most conversations with patients can be undertaken in a
                                                                        quite room away from the bed side
                                                                All Conversations with visitors can be conducted away
                                                                      from the bedside in a private room or area

Staff prevent patient information from being shared      No                  Whiteboards are used in A&E                     6
inappropriately, for example stopping telephone
conversations being overheard, computer screens
being viewed or whiteboards being read.                  Yes      All remaining wards and departments are compliant

Staff ensure that patients remain properly               Yes
clothed/covered when in the ward and when moving
or being moved around the hospital

Quiet rooms or private spaces are available for use      Yes
by staff, patients and visitors.

Staff manage visiting hours and visitor numbers to       Yes
ensure patients are not unduly disturbed by their own
or other patients’ visitors

Staff regularly monitor, evaluate and act upon patient   Yes
perceptions of privacy and dignity. Staff respond
effectively to concerns expressed by patients or their
visitors about privacy and dignity, and mixed sex
 Staff education and training promotes the protection        Yes
 of patient privacy and dignity, and addresses ways in
 which patients' needs and wishes for privacy and
 dignity (including those arising from cultural and
 religious beliefs) can best be met. Staff are aware of
 their role in preserving patient privacy and dignity.

 Nursing care plans encourage specific action to             Yes
 address the individual patient's privacy and dignity.

 Staff are aware of, and abide by, trust policies and        Yes
 guidelines on single-sex accommodation and the
 preservation of patient privacy and dignity. Policies
 are reviewed annually or sooner in the light of
 experience, incidents or changes to the service.

Objective 2 - to achieve the Patient’s Charter standard for segregated washing and toilet facilities across the NHS

                                                              Compliance      Details of non compliance
                        Statement                                                                                             Relates to
                                                                                                                             objective on
                                                                                                                             action plan

 Separate male and female toilets and washing facilities           No         Not on Acorn                                        1
 (other than assisted facilities) are available within the
                                                                              Elizabeth wards                                     2
 ward or department and are clearly labeled.
                                                                              Not all wards have signage on the doors             7

                                                                              Acorn (elective & emergency)                        1
 Appropriate toilet and washing facilities are located             No
 within, or as close as possible to, the patient’s room or
                                                                              Blackthorn (emergency), Chestnut (emergency)        4
                                                                              Curie (emergency), Wavell (emergency)

                                                                              Elizabeth (elective & emergency)                    2

                                                                               Areas of Compliance
                                                                              Acacia (infection control)
                                                                   Beech, Birch, Bracken, Conifer (elderly care -
                                                                 Centenary, EMC - all areas except B bay (medicine
                                                                                   admission units)
                                                                    Nightingale, Faraday (respiratory medicine –
                                                                            Peace / Victory (rehabilitation)
                                                                 Poplar, Primrose, Rowan, Sage, Sycamore, Syringa
                                                                     (Acute surgery - elective and emergency )

To reach toilets and washing facilities, patients do not   No    Acorn (paediatric)                                    1
pass through areas occupied by members of the
                                                                 Chestnut (elderly medicine), Wavell (stroke unit)     4
opposite sex. Where patients pass near to such areas,
adequate screening such as opaque glazing or                                                                           2
blinds/curtains at windows and doors is used to prevent
                                                                                Areas of Compliance
                                                                              Acacia (infection control)
                                                                 Beech, Birch, Blackthorn, Bracken, Conifer (elderly
                                                                                  care - emergency)
                                                                      Centenary, EMC - all areas except B bay
                                                                       (Emergency Medicine admission units)
                                                                         Curie (Acute Medicine - emergency
                                                                    Nightingale, Faraday (respiratory medicine –
                                                                            Peace / Victory (Rehabilitation)
                                                                 Poplar, Primrose, Rowan, Sage, Sycamore, Syringa
                                                                     (Acute surgery - elective and emergency )

Toilets and washing facilities are fitted with internal    No    We need to identify where there are gaps              4
privacy curtains. Staff ensures these are closed when
assisting patients.

Toilets and bathrooms are lockable from the inside,        Yes
with fail-safe entry mechanisms and nurse-call systems
to ensure patient safety.

 Appropriate facilities are provided to uphold the privacy      Yes
 and dignity of patients who are disabled, whether
 temporarily (due to their illness or treatment) or

Objective 3 - to provide safe facilities for patients in hospitals who are mentally ill which safeguard their privacy and dignity

                                                              Compliance                     Details of non compliance                     Relates to
                                                                                                                                          objective on
                                                                                                                                          action plan
                                                                                       Blackthorn (Elderly Care - emergency)                   4
 Patients have their own individual rooms or are                No
                                                                                        Chestnut Elderly Care (emergency)
 accommodated in single-sex dormitories. Sleeping
                                                                                        Curie (Acute Medicine - emergency)
 areas are arranged into separate male and female
                                                                                         Wavell (Stroke Unit - emergency)
 zones, to ensure patient safety.
                                                                                     Elizabeth (Cardiology and CCU - elective &                2
                                                                                    EMC bay B (Level 2 area Medical Emergency                  3
                                                                                             ICU (elective & emergency)

                                                                Yes                           Areas of Compliance
                                                                                             Acacia (infection control)
                                                                                   Beech, Birch, Bracken, Conifer (elderly care -
                                                                                 Centenary, EMC - all areas except B bay (medicine
                                                                                                 admission units)
                                                                                   Nightingale, Faraday (respiratory medicine –
                                                                                          Peace / Victory (rehabilitation)

 Bedroom doors are lockable from the inside, with fail-         No              Facilities to identify as not all side rooms have locks        4
 safe entry and observation mechanisms to ensure                                on doors
 patient safety.

 Separate areas are available within the ward where             No              We no longer have day rooms for patients and
 patients and visitors of the opposite sex are not
permitted. Staff monitor and control access to these             visitors to use on wards

Speedy and robust arrangements are in place to deal        Yes
effectively with patients, staff or visitors who attack,
sexually abuse or harass others.

Alarm systems, call buttons and other security systems     Yes
to alert staff to incidents and emergencies are fitted
and working, and accessible to patients. These are
regularly tested.

Local observation policies are devised taking account      Yes
of guidance contained in Chapter 18 of the Mental
Health Act 1983 Code of Practice.

Patients can choose to have a same-sex key worker.         NA           Not applicable in an acute care setting

Staff working with patients of the opposite sex are        Yes
aware of, and abide by, established policies and
protocols to ensure patient safety.

Staff carrying out physical examinations or using          Yes
restraint on members of the opposite sex are of the
same gender as the patient, or are accompanied by a
chaperone of the same gender as the patient.

Staff carrying out intimate searches are of the same       NA             Not applicable in an acute setting
gender as the patient, and seek the consent of the
patient to undertake the search.

                        Action plan to Address Areas of Non-compliance on the Above Audit:
Issue                         Recommendations                                      Who is      Responsible Due Date       Progress
                                                                                   for Delivery
Action 1

Acorn Ward (Paediatric        We need to seek clarification on the Children’s Lead             Nurse     for 31/08/2008
for       elective      and   National Service Framework particularly in respect to Paediatric
emergency admissions) is      adolescent’s accommodation and the segregation of
non-compliant.                children according to gender versus age.
Sleeping accommodation
in the 11 bed area groups
patients according to their   Depending on the outcome of this review it may be Director of Facilities       30/04/2009
age and not gender.           necessary to proceed to plan alternative arrangements
The Children’s National       for the children/adolescents located on this ward
Service Framework states      This would involve asking the facilitates team to review
that adolescents should       what works can be completed to ensure compliance
ideally be located
alongside other people of
their age.
The shower area is
accessed by walking
through this area and
adolescents are located
nearest the bathrooms.

Action 2
Elizabeth Ward                We will explore how to reorganize the patient Medical Director/Director 30/11/2008
(Cardiology for elective      allocation to Coronary Care Unit to facilitate separation of Nursing
and emergency patients        of the genders
including CCU)
                              Completion of building works may be required Director of Facilities            30/04/2009
We have previously            regarding toilet and shower room access
declared non compliance
to single sex in this area

Issue                          Recommendations                                           Who is      Responsible Due Date    Progress
                                                                                         for Delivery
Action 3                       In accordance with other areas nationally we
Specialist   departments       cannot be single sex compliant in these specific
that we have previously        care areas.
declared non compliance
on :-                          To comply would result in difficulties for
EMC - B bay (level 2 area          Safety
for emergency medical              Operational
admissions)                        Organizational
Intensive Care Unit

Action 4                       We will review the potential for conversion to single     Assistant Director for 30/11/2008
Three Emergency Medical        sex status, inclusive of risk assessment.                 Specialist             and
Care Wards are mixed sex                                                                 Emergency Medicine
and     separates      the     If the wards cannot be converted into single sex status   Director of Facilities
genders by the use of          proceed to the facilities option for separating genders
moveable       partitions.     on each ward area.
This    allows   us      to
maximize     access     for
emergency admissions              Expenditure required to ensure fixed partitions to Director of Facilities    30/10/2008
Blackthorn (emergency)             the fabric of the building, and additional signage
Chestnut (emergency                estimated costs 177K including VAT
Wavell (emergency)                 See detailed report attached
                                   Each ward will need to be decanted

One medical ward is                Each time a ward moves this involves deep clean Director of Facilities       30/04/2009
mixed sex but due to ward          and additional personnel costs of 2.5K per ward.
layout      has     genders
separated by partitions        Without the flexibility of moving the separating Director of Facilities          30/11/08
that are fixed to the fabric   partitions on these ward there will be occasions when Director of Nursing
of the building                we have an increase in the potential for patients to be
Curie (emergency)              placed on the wrong ward area for their gender

                               The facilities option of separating the wards into two Director of Nursing       30/11/2008
                               distinct areas shall have implications for patients
                               safety and ongoing staffing costs

Issue                       Recommendations                                           Who is       Responsible Due Date         Progress
                                                                                      for Delivery
Action 5.                       The Pre-assessment unit gives patients verbal Assistant Director for 30/11/2008
Patient information prior to     information for day surgery but will need to develop Critical Care and Surgery
elective admission does          written information on this topic.
not give information about
single sex bays within a        Patients offer letter inviting them for surgery will Assistant Director for 30/11/2008
mixed sex ward                   need to be amended to give information that they Critical Care and Surgery
                                 may request alternative ward accommodation or
                                 alternatively be offered a different admission date
                                 within one month of the original offer.

Action 6                        Reinforce to all clinical staff the need to use offices   Director of Nursing and 30/08/2008
Patient      information         and quiet rooms to hold private conversations and         Medical Director
regarding ward rounds            to break significant news to patients and families.
and breaking significant
news                            Wards rounds continue to take place in the open Director of Nursing and
                                 patient areas.                                  Medical Director        30/08/2008

                              Review compliance to whiteboards and patient Heads of Nursing                       31/10/2008
                               identification policy.
Action 7.                   The facilities team will review the use of signage and Director of Facilities          31/10/2008
                            bathroom curtains to all non single sex ward areas.
Signage on toilets and      See detailed plan
Action 8                    Monitoring will continue in accordance with policy as
Organisation                follows:
arrangements to secure
good standards of privacy          Clinical site manager obtains an update of Lead Nurse for Clinical Completed                This process has been
and dignity for hospital         each wards positions regarding compliance with Site Management team   Action                   in place since December
patients                         mixed sex policy.                                                     Ongoing                  2006

                                   Circulation of wards that do not comply with Lead Nurse for Clinical Completed
                                 mixed sex policy is sent via the daily Trust Daily Site Management team Action
                                 Report                                                                  Ongoing

                                   If a ward does not comply the Head of Nursing Directorates         Heads   of Completed
                                 then undertakes action to ensure patient is moved Nursing                        Action
                                to an appropriate bed within the 24 hour period                                 Ongoing
                                from admission

                                   If a ward cannot comply with the Trust policy Directorates     Heads    of Completed
                                and a patient is to remain in an inappropriate Nursing                         Action
                                location for over 24 hours the Director of Nursing /                           Ongoing
                                deputy is to be informed

                                   Director of nursing / deputy will ensure that    Director of Nursing        Completed
                                patient is moved to an appropriate bed according                                Action
                                to sex of patient                                                               Ongoing

                                   Work ongoing regularly to identify the Acting Assistant Director Completed
                                constraints that requires staff to place a patient on of Nursing     Action
                                the incorrect bed for their sex                                      Ongoing

                                   Undertake the essence of care privacy and
                                dignity review                                Acting Assistant Director October       (Conducted with in the
                                                                              of Nursing                2008 to April development of essence
                                                                                                        2009          of care programme)
Action 9
Review Trust Policies:

   Single Sex/Mixed Sex       Policy to be reviewed                                Acting Assistant Director 30/11/2008
                                                                                     of Nursing
   Chaperone
                               Is currently being developed. Planned to take to Acting Assistant Director 31/10/2008
                                the next risk management committee               of Nursing

Supporting Evidence
Our PEAT scores are steadily improving with our most recent audit scores showing good for cleanliness, and excellent for food and environment
We have declared non compliance on C21 Standards for Better Health for the last three years.

What have you achieved so far?
The Trust did a massive piece of work at the end of 2005 and during 2006 to reconfigure wards. This resulted in single sex accommodation in the Victorian
and 1930's buildings with mixed sex in Phase 1 and 2. However all 6 wards in Phase 1 and 2 have a footprint of 4 bays (6 beds) and individual single use
Operational Mixed Sex Accommodation Policy
Daily review at bed management meeting and all breaches identified
PEAT audits - have been undertaken
Essence of Care programme underpinning our Privacy and Dignity Action Plan – last reviewed in 2006

Preference of Patient showers from baths to create more toilets - The Trust has already carried out this on some of the ward templates to create more
shower facilities and toilets and would continue this where appropriate in order to reduce the patients travel distances.

The Healthcare Commission selected us for inspection in March 2007 in regard to Dignity and Care in Older People which resulted in positive feedback.
Senior members of the Trust have signed up as ‘Dignity Champions’ to deliver The Dignity Challenge across the organisation ensuring high quality services
that deliver respect to peoples right to dignity and privacy.

What is stopping you from achieving the best practice indicator?

In essence there is no work to be undertaken in the 1930’s block as they are due for disposal within 3-5 year timeframe work or sooner. The Victorian
block will be used as a decanting facility from the 30’s block and as such, work will be undertaken to upgrade the wards to the service being relocated.

What changes might raise standards of privacy and dignity still further?

The Trust has 13 nightingale style wards. The Trust has plans for redevelopment and this would prove both cost effective and be the ideal model for us to
deliver the privacy and dignity agenda.

How will this action plan be monitored?
Internally through the Trust Executive Team that meets weekly
Externally in conjunction with our local PCT through the Clinical quality Indicators meeting that takes place monthly but we have agreed that this will be
reviewed on a quarterly basis

Sheila O’Sullivan / Lesley Marsh
Acting Assistant Director of Nursing / Acting Deputy Director of Nursing
31 July 2008