Central Manchester University Hospitals Foundation Trust is committed to providing private and dignified accommodation for all patients. This plan focuses on maximizing single-sex facilities, patient privacy and dignity, and ensuring all possible steps have been taken. Key actions include allocating resources to improve environments, monitoring performance, and designating separate toilet and washing facilities for men and women in clinical areas.

1. Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009 – March 2010
Central Manchester University Hospitals Foundation Trust (CMFT) is committed to providing the best possible accommodation for patients, which
respects patients’ need for privacy and dignity and enables safe and high quality care to be provided.
This action plan focuses on maximising access to single sex facilities, maximising patients’ privacy and dignity, and reassuring patients that
everything possible has been done.
Best Practice Expectations Outcome Lead Target Progress to Date
Person(s)
Principle Date
1. The board of Ensure that the The Quality Strategy sets out Associate Ongoing Quality Campaign launched May 2009
directors actively board is fully aware the work programme on Director of
support patient’s of the privacy & privacy and Dignity under Patient
privacy & dignity: dignity agenda the work stream of Patient Services
1.1 There is clear Experience and has been
evidence of endorsed by the Board of
commitment by Directors in March 2009
the board of
directors to
improve privacy To publish the As part of CMFT’s Lead Ongoing The Trust Eliminating Mixed Sex
and dignity Trust’s commitment to improving Nurse, Accommodation Improvement Plan and
arrangements commitment in communication with patients Privacy & progress to date, is available on the Trust’s
ensuing privacy & and the public our website is Dignity website for members of the public to
dignity of all its continually being developed access.
local population and the Trust is planning to
and service users Completed CMFT Privacy and Dignity web page
develop a webpage
specifically relating to Lead signed off and available on the Trusts
privacy & dignity, as a Nurse, website from December 2009 for members
means of providing Privacy & of the public to access at
information to patients, Dignity www.cmft.nhs.uk/trust/privacy-and-dignity
visitors and service users
1/12

2. Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009
Best Practice Expectations Outcome Lead Target Progress to Date
Person(s)
Principle Date
1.2 The board of Ensure that the The trust is currently Associate Completed Implementation of the Dr Foster PET data
directors patient experience implementing the use of the Director of collection system for patient experience
understands what is paramount and Dr Foster Intelligence's Patient completed for all in patient clinical areas.
patients want and the board is fully Patient Experience Tracker Services
endeavours to aware of what (PET) an electronic patient Patient feedback on privacy and dignity
deliver it patients want by feedback system to enable questions to be one of series of monthly
analysing the patients to feedback their themes in relation to patient experience
information experience. Patients will be collected via newly implemented PET tool.
gathered from asked questions pertaining Privacy and Dignity feedback to be
patient experience to privacy and dignity weekly collected every 6 months as part of rolling
surveys, for a period of one month programme. Initial data collection
complaints and every 6 months. undertaken in July/August 2009. Next data
incident reports collection via PET devices due
January/February 2010. Ongoing work
with Dr Foster to address data input
challenges and with ward teams to ensure
appropriate coding and sample size is
obtained. Patient experience metrics for
intelligent board agreed currently
developing format for presentation with
Trust.
The board of directors will Associate Ongoing Initial phase of Leadership walks
commence a series of Director of commenced in June 2009, with a plan to
leadership walks from July Patient undertake walks in 60 clinical areas across
2009 to gain direct patient Services the Trust during the first year of
and staff feedback and implementation.
directly observe aspects of
the patients’ experience
which include privacy and
dignity.
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3. Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009
Best Practice Expectations Outcome Lead Target Progress to Date
Person(s)
Principle Date
1.3 The board In line with the Monitoring feedback in Associate From Patient feedback on privacy and dignity
understands the Trust’ Quality terms of privacy and dignity Director of June questions to be one of series of monthly
trust’s Campaign to agree from the Dr Foster Patient 2009 themes in relation to patient experience
performance objectives for Intelligence's patient Services / onwards collected via newly implemented PET tool.
against privacy improvement, that experience tracker (PET) Lead Privacy and Dignity feedback to be
and dignity have been Nurse, collected every 6 months as part of rolling
benchmarks and identified through Privacy & programme. Initial data collection
sets local goals for local and national Dignity undertaken in July/August 2009. Next data
improvement benchmarking collection via PET devices due
January/February 2010. Ongoing work
with Dr Foster to address data input
challenges and with ward teams to ensure
appropriate coding and sample size is
obtained. Patient experience metrics for
intelligent board agreed currently
developing format for presentation with
Trust.
Monthly analysis and Lead Ongoing Data collated via Ward Managers and
monitoring of information Nurse, Monitor Matrons ward rounds reviewed at monthly
gathered from the Privacy & Monthly privacy and dignity meetings and
Matron/Ward Manager ward Dignity appropriate actions identified.
round framework.
Establish a board Quarterly reports to the Director of Jan/Feb Board reports received June and August
reporting Board on privacy and dignity Nursing 2010 2009..
framework to (adults)
enable feedback to
the board on Development of the Associate First phase of leadership walks
privacy and dignity leadership walks Director of Dec commenced and will continue on a rolling
to take place Patient 2009 programme. Review of this process
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4. Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009
Best Practice Expectations Outcome Lead Target Progress to Date
Person(s)
Principle Date
Services framework and how it links with the Matron
Ward Round and Patient Experience
Tracker (PET) to be discussed and patient
experience metrics for intelligent board
agreed currently developing format for
presentation with Trust.
A monthly mechanism to capture patient
experience in relation to privacy and dignity
is established. Data capture tools have
been amended to enable areas to identify
where an incident of ‘mixing’ has occurred.
This will enable monitoring of the provision
of same sex accommodation in line with the
Trust policy and will inform future work
streams.
1.4 Resources are To allocate and A building and refurbishment Director of Ongoing Privacy & Dignity - Eliminating mixed sex
allocated to monitor use of programme is underway for Nursing accommodation (PDEMSA) meetings held
preserving and resources identified the older hospital buildings (adults) monthly to review progress and establish
improving the to ensure the concentrating this year on: / Associate actions.
privacy and dignity privacy & dignity of Director of
of all patients and all patients and • Medical Assessment Estates & Completed Capital refurbishment programme in
service users service users Unit (MAU) Facilities/ progress:
• Emergency Surgical Head of • Medical Assessment Unit refurbishment
Unit (ESU) Nursing completed and opened 26th November
2009.
• Endoscopy unit has moved to same-
sex lists from November 2009.
To ensure that A rolling programme of Associate Surgical Division reconfiguration -
clinical providers improvement works is Director of scheduled refurbishments works extended
have undertaken a planned with PFI partners as Estates and to incorporate life cycle work such as
self assessment of part of the life cycle works facilities/ replacement of ceiling, floors and
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5. Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009
Best Practice Expectations Outcome Lead Target Progress to Date
Person(s)
Principle Date
their current for the hospitals Head of redecoration of these clinical areas.
position in relation Nursing • Emergency Surgical Unit to complete
to mixed sex March 2010 – becoming same-sex wards,
accommodation March located on Ward 1 and Ward 2.
and produced an 2010 • Renal transplant & Urology
improvement plan refurbishment scheduled to complete
as part of their August 2010 - becoming same-sex wards,
plans indicated by August located on Ward 9 and Ward 10.
the SHA 2010
The New Hospitals are fully Associate Complete
compliant with the guidance Director of
on mixed sex Estates and
accommodation Facilities
2 The physical To monitor the The development and Associate Ongoing Ward Manager/Matrons ward round
environment Trusts implementation of the Director of framework captures standards in relation to
actively supports performance in Matron/Ward Manager ward Patient cleanliness and infection prevention and
patients’ privacy relation to round framework in January Services/ control. Review of Matron/Ward Manager
& dignity cleanliness and 2009, ensures that patients’ Corporate Ward Round framework undertaken in
2.1 The care infection experience and patients’ Lead Nurse August and revised elements included in
environment is prevention and environment are evaluated relation of essence of care, patient safety,
clean and well control and is critical to continually and valuing patients. Process to monitor
maintained improving our performance. and review improvements being
established for implementation from
January 2010.
To respond to Ward rounds are undertaken Lead Ongoing Department of Health, Privacy and Dignity
staff, patients and weekly, with specific focus Nurse, Environmental Audit undertaken June 2009
the public when on the environment on a Privacy & which identified three areas as non-
the environment of fortnightly basis. The results Dignity compliant in relation to the environment of
care falls below and actions to address any care:
acceptable identified issues are collated
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6. Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009
Best Practice Expectations Outcome Lead Target Progress to Date
Person(s)
Principle Date
standards and electronically • Clinical Decisions Unit (CLDU)
demonstrate • Programmed Investigations Unit
continuous (PIU)
improvement • Discharge Lounge
Ongoing discussions in relation to options
for these areas are taking place via monthly
mixed sex accommodation meetings.
Interim local policies are being developed
supported by patient information.
Patient information leaflets developed and
Complete implemented.
The cleaning and Associate Ongoing
maintenance of the estate is Director of
the responsibility of our Estates and
subcontractors Sodexo Facilities
Healthcare and Sodexo FM
and is monitored by the
Trust monitoring team
2.2 There is good To repeat a Trust To scope issues relating to Lead Completed The Institute for Innovation and
physical wide audit using mixed sex accommodation. Nurse, Improvement Self Assessment Checklist
separation of the Institute for Privacy & Audit completed in August 2009 for all
sleeping Innovation and Dignity areas providing patient care.
accommodation for Improvement Self
men and women Assessment Analyse and present the Lead Results from the self assessment audit
Complete
Checklist, designed findings and oversee Nurse, collated electronically. Preliminary results
to measure individual action plans Privacy & circulated to the Heads of Nursing and
practice against Dignity / Assistant Directors of Nursing for
eliminating mixed Heads of appropriate actions as required in
sex Nursing/ October/November 2009.
accommodation. Assistant
Director of Action plans to be developed by 14th
Jan 2010
Nursing December 2009, reviewed and monitored
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7. Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009
Best Practice Expectations Outcome Lead Target Progress to Date
Person(s)
Principle Date
by Privacy and Dignity Eliminating Mixed
Sex Accommodation meeting
DoH principles for Agree Trust wide standard Lead Jan 2010 Signage design developed and currently
delivering same for signage to bay/ward Nurse, under consultation.
sex areas. Privacy and
accommodation Dignity
(Sept 09) state that
on mixed-sex
wards bay areas
should be clearly
designated as male
or female
accommodation.
2.3 The physical To repeat the Trust Present findings of the Lead Completed Areas for improvement identified and from
environment is wide scoping scoping exercise and Nurse, privacy & dignity environmental audit
appropriate for the exercise in relation oversee individual action Privacy & undertaken in June 2009.
care group to types of plans, ensuring that all Dignity
accommodation patients are cared for in the
that are used for most appropriate setting for Completed Patient information leaflet: Same-sex
particular care their need, giving due accommodation – ‘we’re making
groups and the consideration of their privacy improvements so you’ll feel more
appropriateness & dignity comfortable’ developed. Distributed within
Trust via Heads of Nursing/Lead Nurses.
Available on the Trusts internet for access
by the public and service users
Completed
‘Pathway specific’ patient information
leaflets now developed for:
 Emergency surgery pathway
 Elective surgery pathway
 Critical Care – Intensive Treatment
Unit (ITU) and High Dependency Unit
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8. Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009
Best Practice Expectations Outcome Lead Target Progress to Date
Person(s)
Principle Date
(HDU)
 Programmed Investigations Unit
(PIU)
 Clinical Decisions Unit (CLDU)
 The Discharge Lounge
Final versions to Trust Information Group
(TIG) for approval and in use by December
2009
2.4 There are To ensure Where wards have mixed Heads of Complete Results from the self assessment audit
segregated toilet designation of gender patients being cared Nursing collated electronically. Preliminary results
and washing single sex toilets for in different bays within a & circulated to the Heads of Nursing and
facilities and washing ward footprint, ensure that Lead Assistant Directors of Nursing for
facilities in clinical the allocation and signage by Nurse, appropriate actions as required in
areas gender is in place for toilet Privacy & October/November 2009.
and washing facilities Dignity
Monitor as part of the Jan 2010 Action plans to be developed by 14th
Matron/Ward Manager ward December 2009, reviewed and monitored
rounds by Privacy and Dignity Eliminating Mixed
Sex Accommodation meeting
3. Individual staff To ensure that the CMFT is currently reviewing Lead Complete CMFT has a ratified policy: ‘Provision of
actions actively Trust has the and revising the privacy & Nurse, Same Sex Accommodation’ which
support privacy & appropriate policies dignity policy in line with Privacy & incorporates national guidance for
dignity and procedures in national policy for delivering Dignity delivering same sex accommodation
3.1 Staff are aware of place and same sex accommodation (DSSA).
and abide by embedded to (DSSA)
policies ensure that the
established to privacy & dignity of Once this policy has been Implementation of policy will take place in
Complete
ensure privacy & patients is ratified it will be available on Lead September / October 2009 as follows:
dignity considered and the Trust’s website to enable Nurse, • Widely circulated throughout the Trust
maintained service users to view Privacy and • Presented at Ward Manager/Lead
Dignity Nurse Forum – Oct 2009
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9. Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009
Best Practice Expectations Outcome Lead Target Progress to Date
Person(s)
Principle Date
• Staff Awareness via team brief – Nov
2009 and ‘insight’ staff newsletter – Dec
2009
• Available on Trust intranet for staff and
Internet by the public & service users – Oct
2009
• Incorporate into Corporate Mandatory
Training Programme – Dec 2009
Bedside curtains redesigned Heads of
to include “Stop – Do Not Nursing Ongoing
Completed implementation within adult
Enter” signs integral to the
Surgical in patient areas. This design of
fabric.
curtains has been implemented in the new
hospital development.
Curtains for the new hospital Lead
build will include this design, Nurse, Ongoing
NHSII audit feedback will identify areas for
as will all new curtains Privacy and
new curtains during next phase.
ordered for wards and Dignity
Work ongoing to develop a specific privacy,
departments.
dignity and respect policy which will be
launched in December 2009.
Privacy and dignity issues go
Completed
beyond the elimination of Lead
As part of the Trusts ‘Quality Strategy’,
mixed sex accommodation Nurse,
CMFT is working in partnership with the
and the policy and action Privacy &
Royal college of Nursing (RCN) to promote
plans will recognise this and Dignity
and embed their ‘Dignity’ Campaign’ –
set out plans for Quality
Delivering Dignified Care and identifying
improvement including, Campaign
‘dignity champions’
information for patients, Manager /
53 staff members of staff have been trained
attitude and behaviour Head of
as ‘dignity champions’.
Nursing - Completed
Medicine
As part of the Quality campaign – ‘Brilliant
Basics’ the Privacy Dignity and Respect
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10. Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009
Best Practice Expectations Outcome Lead Target Progress to Date
Person(s)
Principle Date
launch was held on Friday 27th November
2009. With over 100 in attendance, the
Trust was able to engage both staff and
key external partners on our progress to
date and allowed the dignity champions to
celebrate and share best practice
3.2 Staff apologise for To ensure that the CMFT is to devise patient Lead Complete CMFT has a ratified policy: ‘Provision of
all episodes of appropriate policies information leaflets for both Nurse, Same Sex Accommodation’ which
mixing, and keep and procedures in planned/elective care Privacy & incorporates national guidance for
patients and place and pathways and Dignity delivering same sex accommodation
visitors informed embedded to unplanned/emergency care (DSSA). The policy includes clear
about actions that ensure that the pathways. These leaflets will escalation processes and actions staff are
are being taken to privacy & dignity of fully inform patients and required to take should incidence of non
solve the problem patients is visitors of the provisions of compliance occur. Any incidents are
considered and their care environment, investigated in line with the Trust Risk
maintained. giving due consideration of Management Policy.
their privacy & dignity
Lead Weekly report from incident reporting
Nurse, Ongoing system established to Lead Nurse for
Privacy & Privacy & Dignity and Assistant Director of
Dignity Nursing (Adults) to provide monitoring
mechanism for policy standards.
Any occurrence of Analysis and monitoring of Ongoing Ward managers and matrons ward round
mixing is reported incidents data relating to Lead data now capture from patients who
through the mixed sex accommodation Nurse, feedback they have been cared for in
electronic incident Privacy and ‘mixed sex’ accommodation the location of
reporting system Dignity this. This data is reviewed at monthly
and investigated. privacy and dignity meetings.
Working with Communications Team to
Completed
develop article for the Trust’s magazine
‘Insight’ to increase staff awareness of
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11. Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009
Best Practice Expectations Outcome Lead Target Progress to Date
Person(s)
Principle Date
policy and Trust improvement plan.
Completed Article planned for ‘Quality Matters’ trust
quality newsletter and web update via the
Quality web site to take place December
2009.
Jan 2010 Article planned in January patient safety
and risk management newsletter ‘Lesson
Learnt’.
3.3 Staff report To ensure that the Analysis and monitoring of Lead Ongoing CMFT has a ratified policy: ‘Provision of
episodes of appropriate policies incidents data relating to Nurse, Monitoring Same Sex Accommodation’ which
mixing through the and procedures in mixed sex accommodation Privacy & incorporates national guidance for
appropriate place and Dignity delivering same sex accommodation
channels embedded to (DSSA). The policy includes clear
ensure that the escalation processes and actions staff are
privacy & dignity of required to take should incidence of non
patients is compliance occur. Any incidents are
considered and investigated in line with the Trust Risk
maintained. Management Policy
Any occurrence of
mixing is reported Weekly report from incident reporting
through the Ongoing system established to Lead Nurse for
electronic incident Monitoring
Privacy & Dignity and Assistant Director of
reporting system Nursing (Adults) to provide monitoring
and investigated mechanism for policy standards.
Ward managers and matrons ward round
Ongoing
Monitoring data now capture from patients who
feedback they have been cared for in
‘mixed sex’ accommodation the location of
this. This data is reviewed at monthly
privacy and dignity meetings
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12. Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009
Best Practice Expectations Outcome Lead Target Progress to Date
Person(s)
Principle Date
Complaints and PALS Associate Ongoing
information analysed Director –
monthly Patient
Services
Matrons/Ward Manager Lead Nurse Ongoing
ward rounds to access Privacy &
patients views Dignity
Feedback from the patient Associate Jan
experience tracker (PET) in Director of 2010
relation to privacy and Patient
dignity to be analysised and Services
actions agreed where
issues have been identified.
Board of directors receive Director of Reporting framework under development in
information through the Informatics order to report patient experience indicators
intelligent board reports – & Associate for nursing, such as privacy and dignity on
patient experience Director of regular basis to the Board. Patient
indicators Patient experience metrics for intelligent board
Services agreed currently developing format for
presentation with Trust.
Version 7 – December 2009 12/12