ELIMINATING MIXED SEX ACCOMMODATION POLICY
Document name:
Eliminating mixed sex accommodation (EMSA) policy
Document type:
Trust-wide policy and procedures
What does this policy
replace?
New Policy
Staff group to whom it
applies:
All Staff
Distribution:
Trust-wide
How to access:
Trust intranet
Issue date:
December 2014
Next review:
December 2017
Approved by:
Executive Management Team – 04.12.14
Developed by:
EMSA Review Group
Director leads:
Director of Nursing, Clinical Governance and Safety
Contact for advice:
Assistant Director Nursing – Safeguarding Lead
Assistant Director Compliance
1
CONTENTS
1. Introduction
………………………………………………………………………….
3
2. Purpose
………………………………………………………………………….
4
3. Duties and Responsibilities
………………………………………………………………………….
4
4. Process
………………………………………………………………………….
6
5. Stakeholder Involvement
………………………………………………………………………….
7
6. Equality Impact Assessment
………………………………………………………………………….
7
7. Document Approval
………………………………………………………………………….
8
8. Dissemination and Implementation
………………………………………………………………………….
8
9. Review and Revision Arrangements
………………………………………………………………………….
8
10. Monitoring
………………………………………………………………………….
8
11. References
………………………………………………………………………….
8
APPENDICES
Appendix 1 – Definitions
………………………………………………………
9
Appendix 2 – Breaches
………………………………………………………
10
Appendix 3 – DSSA Principles
………………………………………………………
12
Appendix 4 – DSSA in Mental Health and Learning
Disabilities
………………………………………………………
13
Appendix 5 – Professional Letter
………………………………………………………
17
Appendix 6 – Equality Impact Assessment Tool
………………………………………………………
24
Appendix 7 – Checklist for review and approval of
Procedural Document
………………………………………………………
26
2
1.
INTRODUCTION
Every service user has the right to receive high quality care that is safe, effective and
respects their privacy and dignity. Responsibility for these rights does not lie with one
individual or group, but with all staff at all levels. The South West Yorkshire
Partnership NHS Foundation Trust is committed to providing every service user with
same sex accommodation, because it helps to safeguard their privacy and dignity
when they are often at their most vulnerable.
The Trust provides same sex accommodation in line with the Delivering Same Sex
Accommodation (DSSA) 17 principles and DSSA in mental health and learning
disability guidance (Appendices 3 and 4). All accommodation is either single
bedrooms or gender specific wards. Unjustified mixing breaches would therefore not
be anticipated. However, organisationally the Trust takes account of national
guidance and information to ensure that service provision reflects best and evidencebased practice. An annual audit is conducted to ensure learning is facilitated and
practice improved.
Commitment to elimination of mixed-sex accommodation (MSA) was stated in the
2011-12 NHS Operating Framework - “All providers of NHS funded care are
expected to eliminate mixed-sex accommodation except where it is in the overall
best interest of the patient”. A professional letter (Ref: PL/CNO/2010/3) sent by the
Department of Health in November 2010 updated NHS trusts on requirements with
regard to recognising, reporting and eliminating breaches of this policy. This letter
(appendix 5) details the criteria and identifies the circumstances which would
constitute a breach. Avoidance of MSA breaches ‘in accordance with the
professional letter’ is referenced within the NHS Standard Contract.
National reporting of unjustified mixing (i.e. breaches – see appendix 2) in relation
to sleeping accommodation commenced on 1 December 2010. MSA breach data is
collected monthly from all NHS providers and other organisations that provide NHSfunded care (including Independent and Voluntary Sector organisations). Data are
collected, validated and published in accordance with the Code of Practice for
Official Statistics. “Sleeping accommodation” includes areas where patients are
admitted and cared for on beds or trolleys, even where they do not stay overnight.
The NHS must also monitor justified mixing (which does not constitute a breach)
in sleeping accommodation, mixed-sex sharing of bathroom / toilet facilities
(including passing through accommodation or toilet/bathroom facilities used by the
opposite gender), and mixed provision of day space in mental health units at a local
level.
The Trust is expected to make a declaration to commissioners by 31 March each
year to confirm the Trust’s position regarding compliance with the Eliminating Mixed
Sex Accommodation (EMSA) standard. The statement of compliance is then
required to be posted on the Trust website. Organisations that either do not make a
declaration or declare they are not compliant will face penalties.
There has not previously been a trust-wide EMSA policy so this policy does not
replace or supersede a previous version. The policy has been developed by the
EMSA Review Group.
3
2.
PURPOSE
The purpose of the policy is to


ensure that the Trust appropriately monitors, reports against and maintains best
practice re: EMSA
provide direction to staff to enable them to provide care and treatment in a way
which treats service users with respect and maintains their right to privacy and
dignity.
The Trust policy requirements are to meet the standards expressed in DSSA
guidance and in the professional letter (appendices 3-5).
3.
DUTIES AND RESPONSIBILITIES
3.1 Scrutiny by the Trust Board and appropriate committee
Trust Board responsibility for assurance, scrutiny of the processes and
outcomes in relation to this policy will be executed through the Clinical
Governance and Clinical Safety Committee and Executive Management
Team structures, which will keep the Trust Board informed and ultimately
assured that the system is working effectively.
3.2 The Executive Management Team (EMT) will have overall responsibility
for management of EMSA and will:
 Nominate the Accountable Director
 Receive reports from the accountable director and lead organisational group
 Approve and sign off organisational action plans resulting from any EMSA
breaches and the annual audit against best practice standards
3.3 Accountable Director
The Accountable Director for this policy is the Director of Nursing, Clinical
Governance and Safety. The Accountable Director will
 ensure completion of the annual declaration of compliance for
commissioners and publication of this on the Trust website
 ensure commissioners (and regulators where appropriate) are informed
should any EMSA breach occur.
3.4 BDU Directors and Deputy Directors
BDU directors and deputy directors are responsible for:
 Ensuring compliance with EMSA policy
 Investigating and implementing action where EMSA issues are identified
 Ensuring bed management processes include and adhere to EMSA
requirements
4
3.5 Lead Group
The EMSA review group is responsible for:
 quarterly EMSA incident monitoring
 annual EMSA best practice audit
 identification of any deficits in practice
 facilitating appropriate improvement action by ward and Business Delivery
Unit
 advising on inclusion of EMSA issues on relevant risk registers
 EMSA policy review and updating
3.6 Trust Patient Safety Team
Responsible for monthly reporting of any EMSA breaches identified via DATIX
incident reporting
3.7 Ward/Unit Manager and Matrons
Ward/unit managers and matrons are responsible for:
 Making staff aware of this policy, its content and where to access the policy
 Risk management of the ward in regard to mixed sex and privacy and dignity
 Reporting of any non-compliance or concerns about any poor practice by
staff to the relevant BDU General Manager
 Assisting in the investigation of any failure to comply with the policy
 Taking corrective action to improve privacy and dignity and prevent EMSA
breaches
 As required, ensuring staff are aware of any processes and responsibilities
in regard to acting as a chaperone
3.8 Individual Staff Members
Staff are responsible for:
 Actively promoting privacy, dignity and respect for the individual
 Ensuring that all service users are cared for in single sex accommodation
 Risk assessment and management of vulnerable adults in areas where
gender mixing occurs for therapeutic purposes
 Reporting any EMSA incidents
 Being aware of their role if acting as a chaperone
5
4.
PROCESS
4.1 Accountable director
Will ensure
 that the Trust has established appropriate processes to monitor, review and
report against EMSA as well as facilitating improvement where required
 production and publication of the Trust’s annual EMSA declaration
4.2 BDU Directors and Deputy Directors
Will ensure that
 there are appropriate BDU processes to enable EMSA compliance
 where EMSA incidents or EMSA related trends are identified the
appropriate investigative procedures are completed and relevant action
implemented
4.3 Lead Group
The EMSA Review Group membership consists of a senior officer direct report
to the lead Director, clinical and managerial representation from each BDU and
Quality Academy members to specifically provide advice and support in regard
to quality standards and audit. The group will:
 conduct quarterly reviews of all recorded EMSA incidents alerting the
lead Director to any significant trends or issues of concern
 communicate relevant concerns to BDU directors with advice for inclusion on
appropriate risk registers
 ensure that any concerns/issues regarding the manner in which incidents are
reported or risk gradings given are communicated back to relevant ward
managers for appropriate remedial action
 ensure completion of the annual EMSA best practice audit
 ensure the EMSA policy is reviewed and updated in line with the specified
policy review schedule
4.4 Trust Patient Safety Team
Will conduct monthly reporting of any EMSA breaches identified via DATIX
incident reporting in support of contractual/regulatory requirements.
6
4.5 Ward/Unit Manager and Matrons
Will ensure that
 all ward/unit staff are aware of this policy, its content and how to access it
 all ward/unit staff are aware of what constitutes an EMSA breach and how to
report any EMSA related incidents
 any non-compliance or concerns about poor practice is reported to the
relevant BDU General Manager
 ward information leaflets/literature clearly specify the nature of the
accommodation both in regard to single sex sleeping arrangements and
shared areas for social/therapeutic purposes.
 Will assist in the investigation of any failure to comply with the policy taking
corrective action to improve privacy and dignity and prevent EMSA
breaches.
4.6 Individual Staff Members
With reference to the EMSA definitions and criteria given as appendices within
this policy document – all staff must
 Actively promote the service user’s privacy and dignity at all times
 Ensure that all service users are cared for in single sex accommodation
 Report any EMSA incidents on the Trust’s Incident reporting System
(DATIX) and to their line manager
 Ensure that all equality and diversity matters are taken account of in care
planning so that individual care plans include personal preferences and
personal gender specific requirements
 Be aware of their role if acting as a chaperone
5.
STAKEHOLDER INVOLVEMENT
The following identifies some of the individuals or groups who have been
consulted during the development of this policy.
 Executive Management Team Approval
 Director of Nursing, Clinical Governance and Safety
 EMSA Review Group Members
6.
EQUALITY IMPACT ASSESSMENT AND REVIEW & APPROVAL
CHECKLIST
Completed and provided as appendices 6 and 7
7
7.
DOCUMENT APPROVAL
This policy has been reviewed by the Trust Policy Review Group and approved
by the EMT, which has overarching responsibility for the approval, development
and review of this document, including any amendments following review.
8.
DISSEMINATION & IMPLEMENTATION
This document will be disseminated centrally in line with the Trust policy for the
development, approval and dissemination of policy and procedural documents.
Staff will be alerted to the policy and to any new versions at service and team
meetings via the Trust’s Briefing process. Implementation of this policy will be
through the key roles and responsibilities of the accountable director and the
Executive Management Team. The EMSA review group will facilitate
understanding and implementation via targeted communication with BDU
Deputy Directors, Clinical Leads and General Managers.
9.
REVIEW AND REVISION ARRANGEMENTS INCLUDING VERSION
CONTROL
9.1
Process for review of this document - This document will be
reviewed in line with Trust processes at least every 3 years and re-issued on or
before the review date identified on the front cover.
9.2
Version control - The front cover indicates the version, date of issue
and review date of this document. Following each review the policy will be
issued as a new version, whether or not there have been changes to the
content. The most recent version will be available on the Trust intranet.
10. MONITORING
 EMSA Review Group minutes and EMSA annual declaration will provide
evidence of ongoing monitoring and review
 Any EMSA breaches will be reported in the monthly Trust Board
performance report
 Clinical Governance and Clinical Safety Committee minutes will provide
evidence of scrutiny by Trust Board
11. REFERENCES
 NHS 13-14 Standard Contract
 PL/CNO/2010/3, Professional Letter, Department of Health
 DSSA Principles, September 2009, Department of Health, Gateway
Reference: 12610
 DSSA in Mental Health and Learning Disabilities, December 2009,
Department of Health, Gateway Reference: 12940
8
APPENDIX 1 – DEFINITIONS
Same Sex Accommodation
The definition of same sex accommodation was described as follows by the
Department of Health in February 2011 : where male and female patients sleep in
separate areas and have access to toilets and washing facilities used only by their own
sex. Same-sex accommodation can be provided both in single-sex and mixed-sex
wards.


In a same-sex ward the ward is occupied solely by either men or women and has its
own dedicated toilet and washing facilities.
In mixed-sex wards, same-sex accommodation can be provided either as:
o single rooms with same-sex toilet and washing facilities (preferably en-suite)
or
o multi-bed bays or rooms occupied solely by either men or women with their
own same-sex toilet and washing facilities. A bay is a sleeping area which is
fully enclosed on three sides with solid walls (not curtains – they offer little
privacy and do not provide a safe and secure environment). A fourth side may
be open or partially closed. The fourth side might need to be open for patient
safety reasons, but the open fourth side should not face into a bay occupied
by members of the opposite sex.
Patients should not need to pass through mixed communal areas or sleeping areas,
toilet or washing facilities used by the opposite sex to get to their own. The only
exception is fully dressed patients placed in day areas who need to access toilet
facilities.
In addition Mental Health are required to have the availability of single sex day rooms.
Privacy
Refers to freedom from intrusion and relates to all information and practice that is
personal or sensitive in nature to an individual (DOH 2009).
Dignity
Is concerned with how people feel, think and behave in relation to the worth or value of
themselves and others. To treat someone with dignity is to treat them as being of worth,
in a way that is respectful of them as a valued individual. In care situations, dignity may
be promoted or diminished: by the physical environment: organisational culture; by the
attitudes and behaviour of the nursing team and others and by the way in which care
activities are carried out. Dignity applies equally to those who have capacity and to those
who lack it. (RCN 2008). In addition the ‘Dignity in Care Campaign’ suggested that
dignity issues overlap with four other areas:
 Respect- Shown to a person as a human being and as an individual, by others, and
demonstrated as courtesy, good communication and taking time.
 Privacy- In terms of personal space: modesty and privacy in personal care; and
confidentiality of treatment and personal information.
 Self Esteem, Self-worth, Identity and a sense of oneself; promoted by all the
elements of dignity but also by ‘all the little things’- a clean and respectable
appearance, pleasant environments and by choice and being listened to.
 Autonomy - Including freedom of act and freedom to decide on opportunities to
participate, and clear comprehensive information
9
APPENDIX 2 – BREACHES
Delivering Same-Sex Accommodation (DSSA)
Yorkshire and the Humber PCT Consensus on Breaches*
DSSA Principles

There are no exemptions from the need to provide high standards of privacy and dignity.

Males and females should not have to sleep in the same room, unless sharing can be justified by the need for
treatment, or by patient/service user choice.

Males and females should not have to share mixed bathing and WC facilities, unless they need specialised
equipment such as hoists or specialist baths.

Patients/Service users should not have to pass directly through opposite-sex areas to reach their own facilities.

In some circumstances, mixing of the sexes can be justified. Decisions should be based on the needs of each
individual patient/service user, not the constraints of the environment, or the convenience of staff.

Where mixing of sexes does occur, it must be acceptable and appropriate for all the patients/service users
affected.
This guidance includes:

In General Ward Areas (Acute and Community settings)

Specialist Units

Mental Health and Learning Disability accommodation

Children’s and young people’s services

The same standards should apply to all NHS commissioned care.
There should be a culture of zero tolerance to the mixing of sexes.
In General Ward Areas
A breach is defined as occurring when males and females are required to share sleeping accommodation or where they
have to pass through an area of opposite sex accommodation to access toilets/bathrooms or their own sleeping
accommodation.
It is acceptable to have toilets and washing facilities that can be allocated to men or women according to need, as long as
there is good signage to make it clear which sex is designated at any particular time. "Passing through" opposite sex areas
covers situations where patients have to pass between or across the foot of beds occupied by the opposite sex (e.g.
through an occupied room or bay). It also includes wards where patients might perceive that they had.
The breach occurs as soon as the above circumstances happen and lasts until they are resolved.
The number of breaches caused by a particular event will be equal to the total number of patients affected (1 female in
a bay with 5 males is 6 breaches).
Where mixing of the sexes is unavoidable, the situation should be rectified as soon as possible. The patient, relatives,
carers and/or advocate 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.
When a breach occurs an organisational escalation policy should be implemented. This should quickly escalate the
breach to an executive level.
It is good practice to undertake a Root Cause Analysis and implement the lessons learned.
Specialist Units
(including Critical Care, High Dependency, Acute Stroke Units, Acute Assessment Units and Post Operative Recovery)
This guidance should be read in combination with that given on the DSSA website
http://www.dh.gov.uk/en/Healthcare/Samesexaccommodation/Practicalsupport/DH_111408
10
In these types of units which deliver highly technical care, often in emergency situations, to highly dependant patients
every effort should be made to provide single sex accommodation but it is recognised that in some decisions to mix will
occur based on the clinical need of an individual or group of patients. (clinical justification)
In these settings a breach will occur when an individual or group of patients continue to be accommodated in the mixed
environment when their clinical condition no longer requires this. Because of the logistics of bed management it may be
relevant to apply this breach definition following a reasonable time lapse in order to facilitate the patients relocation to
more suitable same-sex accommodation
Whilst in principle the breach will affect all patients in the unit the practical application will be only to those patients
who are now inappropriately placed because of their changed clinical condition.
The placing of patients in mixed sex assessment units merely to accommodate them or achieve A&E targets, without a
valid clinical reason for this “decision to mix” places these patients in the same position as those in general wards
(above).
Mental Health and Learning Disability accommodation
In these settings commissioners and providers of service should aspire to provide single room en-suite accommodation. It
is also a requirement of policy that a female only lounge is also provided.
For the purposes of determining when a breach has occurred, the rules for general wards should apply. In addition a
breach will also occur when there is a failure to provide a female only lounge. The number of breaches in this case will
be the total number of females denied this facility.
Children’s and young people’s services
In these settings a breach will occur when a child or young person (parent where applicable) is not able to exercise their
choice for same-sex accommodation rather than mixed sex accommodation based on clinical need, age or stage of
development. Providers of children’s services will need to be able to demonstrate how children (parents) have exercised
this choice.
EXTRACT FROM NHS 2013/14 STANDARD CONTRACT
Ref
Operational
Standards
Threshold
(2013/14)
Method of
Measurement
(2013/14)
Consequence
of breach
Monthly or annual
application of
consequence
Applicable
Service
Category
>0
Verification of
the monthly data
provided
pursuant to
Schedule 6 Part
C in accordance
with the
Professional
Letter
£250 per day
per patient
affected
Monthly
A, CR, S,
MH, C
Mixed sex
accommodation
breaches
CB_B
17
Sleeping
Accommodation
Breach

SLEEPING ACCOMMODATION – includes any areas service users are admitted and cared
for on beds or trollies, even where service users do not stay overnight, all admissions and
assessment units (including clinical decision units) and day surgery and endoscopy units. It
does not include areas where patients have not been admitted, such as accident and
emergency cubicles.

SLEEPING ACCOMMODATION BREACH – an unjustified episode of mixed sleeping
accommodation as set out in Appendix A of the Professional Letter
11
APPENDIX 3 - DSSA 17 PRINCIPLES
12
APPENDIX 4 – DSSA IN MENTAL HEALTH AND LEARNING DISABILITIES
13
14
15
16
APPENDIX 5 - PROFESSIONAL LETTER
17
18
19
20
21
22
23
Appendix B - Equality Impact Assessment Tool
To be completed and attached to any policy document when submitted to the Executive Management Team for
consideration and approval.
Date of Assessment: ________________________________
APPENDIX 6 – EQUALITY IMPACT ASSESSMENT TOOL
To be completed and attached to any policy document when submitted to the Executive Management
Team for consideration and approval.
1
2
Equality Impact Assessment
Questions:
Name of the document that you are
Equality Impact Assessing
Describe the overall aim of your
document and context?
Evidence based Answers & Actions:
Eliminating Mixed Sex Accommodation Policy


3
4
5
Who will benefit from this
policy/procedure/strategy?
Who is the overall lead for this
assessment?
Who else was involved in
conducting this assessment?
to ensure that the Trust appropriately monitors, reports
against and maintains best practice re: EMSA
to provide direction to staff to enable them to provide care
and treatment in a way which treats service users with
respect and maintains their right to privacy and dignity.
 Service users and staff
Director of Nursing, Clinical Governance & Safety
Have you involved and consulted
service users, carers, and staff in
developing this
policy/procedure/strategy?
 Assistant Director Compliance
 Assistant Director Nursing
 EMSA Review Group
Staff consulted via membership of EMSA Review Group and some
Trust Specialist Advisors
What did you find out and how
have you used this information?
What equality data have you used
to inform this equality impact
assessment?
What does this data say?
Amendments made in line with minor changes suggested
8
Taking into account the
information gathered
above, could this policy
/procedure/strategy affect
any of the following
equality group
unfavourably:
Yes/
No
Evidence based Answers & Actions. Where Negative impact has
been identified please explain what action you will take to
remove or mitigate this impact.
8.1
8.2
8.3
8.4
8.5
8.6
Race
Disability
Gender
Age
Sexual Orientation
Religion or Belief
No
No
No
No
No
No
N/A
N/A
N/A
N/A
N/A
N/A
6
7
None
N/A
24
8.7
8.8
8.9
8.10
9
9a
Transgender
No
Maternity & Pregnancy
No
Marriage & Civil
No
partnerships
Carers*Our Trust
No
requirement*
What monitoring arrangements are
you implementing or already have
in place to ensure that this
policy/procedure/strategy:Promotes equality of opportunity
for people who share the above
protected characteristics;
9b
Eliminates discrimination,
harassment and bullying for people
who share the above protected
characteristics;
9c
Promotes good relations between
different equality groups;
9d
Public Sector Equality Duty – “Due
Regard”
Have you developed an Action Plan
arising from this assessment?
10
11
12
Assessment/Action Plan approved
by
Once approved, you must forward a
copy of this Assessment/Action Plan
to the Equality and Inclusion Team:
inclusion@swyt.nhs.uk
N/A
N/A
N/A
N/A
Policy applies equally to all service users and staff
EMSA breaches are monitored and would be
investigated/reported to commissioners
Annual best practice audit provides opportunity to identify if
there are any issues/trends related to protected characteristics ,
relationships between different groups and ‘due regard’
No
Executive Management Team as part of final policy approval
Please note that the EIA is a public
document and will be published on
the web.
Failing to complete an EIA could
expose the Trust to future legal
challenge.
If you have identified a potential discriminatory impact of this policy, please refer it to the Director of Corporate
Development or Head of Involvement and Inclusion together with any suggestions as to the action required to
avoid/reduce this impact.
For advice in respect of answering the above questions, please contact the Director of Corporate Development
or Head of Involvement and Inclusion.
25
APPENDIX 7 – CHECKLIST FOR REVIEW AND
APPROVAL OF PROCEDURAL DOCUMENT
To be completed and attached to any policy document when submitted to EMT for consideration and
approval.
Yes/No/
Unsure
Title of document being reviewed:
1.
2.
Title
Is the title clear and unambiguous?
Y
Is it clear whether the document is a guideline,
policy, protocol or standard?
Y
Is it clear in the introduction whether this
document replaces or supersedes a previous
document?
Y
Rationale
Are reasons for development of the document
stated?
3.
4.
5.
Y
(purpose of the policy)
Development Process
Is the method described in brief?
Y
Are people involved in the development
identified?
Y
Do you feel a reasonable attempt has been
made to ensure relevant expertise has been
used?
Y
Membership of EMSA review
group
Is there evidence of consultation with
stakeholders and users?
N
Not Applicable – the policy is
confirmation of practice
against national directives for
staff
Content
Is the objective of the document clear?
Y
Is the target population clear and
unambiguous?
Y
Are the intended outcomes described?
Y
Are the statements clear and unambiguous?
Y
Evidence Base
Is the type of evidence to support the
document identified explicitly?
Y
Are key references cited?
Y
Are the references cited in full?
Are supporting documents referenced?
6.
Comments
Y
Approval
Does the document identify which
committee/group will approve it?
Y
26
Yes/No/
Unsure
Title of document being reviewed:
Comments
If appropriate have the joint Human
Resources/staff side committee (or equivalent)
approved the document?
7.
Dissemination and Implementation
Is there an outline/plan to identify how this will
be done?
Does the plan include the necessary
training/support to ensure compliance?
8.
N/A
Document Control
Does the document identify where it will be
held?
Have archiving arrangements for superseded
documents been addressed?
9.
Y
Y
N/A
Process to Monitor Compliance and
Effectiveness
Are there measurable standards or KPIs to
support the monitoring of compliance with and
effectiveness of the document?
Y
Quarterly EMSA incident
review
Annual best practice audit
Investigation of any EMSA
breaches
Is there a plan to review or audit compliance
with the document?
10.
11.
Y
As above
Is the review date identified?
Y
Policy Review date 2016
Is the frequency of review identified? If so is it
acceptable?
Y
Review Date
Overall Responsibility for the Document
Is it clear who will be responsible
implementation and review of the document?
27
Y