Policy and Procedures to ensure the

Privacy and Dignity of Users of Health Services

1.1Document Control

Purpose / The purpose of this policy is to ensure that users of health services provided by SwindonPrimary Care Trust (PCT) are treatedwith dignity and respect and given their privacy when required or requested.
Author / Linda Baxter, Clinical Standards and Policy Manager
Aileen Davies, Clinical Governance Quality Manager
Application / Organisation wide all PCT staff
Implementation date / 14th April 2010
Date of review / January 2012
Expiry date / 31stMarch 2012
Link to Standards for Better Health / C13a Dignity and Respect
C13b Consent
C16 Accessible information
C17 Patient and public involvement
C18 Choice and equity
C20a Care Environment and Amenities
Link to Care Quality Commission
Quality and Safety Standards / Outcome 1Respecting and involving people who use services
Outcome 2 Consent to care and treatment
Outcome 4 Care and welfare of people who use services
Outcome 10 Safety and suitability of premises
Outcome 12 Requirements relating to workers
Outcome 16 Assessing and monitoring the quality of service provision
Link to NHSLA Risk Standard(s) / Not applicable
Responsibility for implementation / Directors, commissioning and service managers
Document Reference No:
(Allocate from Policy Register) / GP067 version 3
Equality and Diversity / Swindon Primary Care Trust is committed to promoting equality in all its responsibilities – as commissioner of services, as a provider of services, as a partner in the local economy and as an employer. The PCT’s policies will make sure, through equality impact assessments,that all users and potential users of services and employees are treated fairly and with respect whatever their age, disability, gender, race, religion and beliefs and sexual orientation.
This document has had an impact assessment against race, disability, gender, age, sexual orientation and religion and belief equality and diversity criteria in line with current legislation and the requirements of the Single Equality Scheme
Date of Equality Impact Assessment / 15th January 2010
Links with other documents / Child Protection policy
Consent policy
Infection Control Manuals
Information Governance Policy
Record Management policy and procedures
Safeguarding vulnerable adults policy
Single Equality Scheme
Whistle blowing policy
Zero tolerance policy
Mental Capacity Act
Deprivation of Liberties Safeguards
Policy Statement / It is the responsibility of staff at all levels to ensure that they are working to the most up to date and relevant policies and procedures. By so doing, the quality of services offered will be maintained and the chances of staff making erroneous decisions, which may affect patient, staff or visitor safety, will be reduced.

1.1.1 Review and Approval History

Version / Reviewer/Approver / R/A / Outcome / Date
2 / Linda Baxter
Aileen Davies / R / Development of version 3 / 01/12/09
3 / Professional Forum / R / Reviewed from clinical/professional perspective / April 2010
3 / Clinical Governance & Patient Safety Forum / R / Approved for ratification by Provider Services Committee / 13/4/2010
3 / Provider Services Committee / A / Ratified for publication

1.1.2 Consultation and Revision History

Version / Status / Outcome / Date / Name and Title
3 / Draft / Created following review of draft 2 / 01/12/09 / Linda Baxter
Aileen Davies
3 / Draft / For comment / 15/01/10 / Provider Services Managers
Children’s services
Asst Director of Quality
Head of PALS, complaints & PPI
PCT Equality & Diversity
Lead
3 / Draft / Minor additions and corrections / 29/01/10 / Hilary Sinclair,
Head of Urgent Care and Specialist Nursing.
Chris Woodward, Child health Service Manager
Sue Vallis, Senior Community Nurse, Learning Disability Service.
Femi Olayisade, PCT Equality & Diversity Lead
Rachel Green, Ward Manager
SwICC
3 / Draft / Addition of reference to Safeguarding Adults and No Secrets / 10/03/10 / Doug Bale, Head of Service – Safeguarding Adults
3 / Draft / Comments received / 10/3/10 / Judith Blackstock, Assistant
Director of Quality & Clinical
Governance
Gary Latham, Acting Team Manager Adult Social Care
Debra Brown, Therapy Manager, GreatWesternHospital
Kim Hogan, Community Matron
Paul Dryden, Medical Director, Clover Centre
3 / Draft / Approved with inclusion of equality statement in document control section / 13/4/10 / Diversity Steering Group

Part 1 Privacy and Dignity Policy

1.2 Contents Page

1.1 Document Control2

1.2 Contents5

1.3 Introduction6

1.4 Purpose6

1.5 Definitions6

1.6 Principles7

1.7 Responsibilities8

1.8 Ratification10

1.9 Training10

1.10 Monitoring framework10

Appendix 1

Equality Impact Assessment Report11

1.3 Introduction

The NHS Constitution states that all patients have the right to privacy and to betreated with dignity and respect.Swindon Primary Care Trust (PCT) is fully committed to this principle for all users of its services.

Swindon PCT will adhere to the 17 principles which support Delivering Same Sex Accommodation (DSSA) policy and guidance.

1.4 Purpose

The purpose of this policy is to ensure that:

  • All users of health services provided by Swindon (PCT) are treated with dignity,respect and privacy at all times.
  • All providers of NHS care have virtually eliminated mixed sex accommodation
  • To highlight that a breach of same sex accommodation can be reported to the PCT by anyone. This includes the patient, their representative /carer and members of staff.
  • Appropriate organisational arrangements are in place to secure acceptable standards of privacy and dignity at all times.

This policy does not cover privacy and dignity issues in GP practices or independent contractors premises unless PCT employees normal place of work is on these premises. The privacy and dignity arrangements for independent contractors are managed by the individual practices and this policy will be strongly recommended to them as good practice guidance.

1.5 Definitions

Privacy is defined as “freedom from intrusion.”

Dignity is a term used to signify that a being has an innate right to respect andethical treatment.

Respect means to hold in esteem or honour to show regard or consideration for.

Modestycomprises a set of culturally or religiously determined values that relate to the presentation of the self to others.

Same-sex accommodation is where specific sleeping areas, toilet and washing

facilities are designated as either men-only or women-only.

Same-sex accommodation can be provided in:

• same-sex wards, where the whole ward is occupied by men or women only

• single rooms

• mixed wards,where men and women are in separate bays or rooms.

Toilet and washing facilities should be easily accessible and, ideally, either inside ornext to the ward, bay or room.

Breaching standards for same sex accommodation; a breach is when a patient is placed within a clinical setting where one or more of the following criteria apply;

  • The patient occupies a bed in a bay or room that is occupied by a patient of the opposite gender
  • The patient occupies a bed that does not have access to co-located same – sex toilet and washing facilities.
  • The patient must pass through an area designated for occupation by patients of the opposite gender to gain access to toilet and washing facilities
  • The patient occupies a bed in a bay or room that is occupied by a patient of the opposite gender where a clinical justification previously applied is no longer applicable

Clinical Justification; in some situations it may be clinically justified for care to be delivered or urgent treatment to be given irrespective of the availability of same sex accommodation. This fine judgement needs to be made on an individual basis.

Transgenderrefers to anyone who has proposed commenced or completed reassignment of gender or anyone who lives continuously or temporarily in the gender role that is opposite to their natal sex.

Mental capacityis the ability to make a specific decision, or take action, at the time this decision or action needs to be taken (based on OPG 606 DOH March 2009). Provisions relating to persons who lack capacity are laid out in the Mental Capacity Act 005.

1.6 Principles

  • Care and treatment will be delivered in a way which acknowledges that each person is anindividual.Providers of care will work closely with the individual and/or their carer (with theindividuals consent) to plan and review their care and treatment.
  • Individuals will receive care in a manner which recognises their own values, beliefs and personal relationships. The personal space of individuals and their relatives or carers will be respected at all times.
  • Staff are also entitled to expect that patients and their relatives and carers will recognise their individual values beliefs and personal relationships and will respect the staff member’s personal space.
  • Communication with individuals will take place in a manner that respects their individual knowledge, abilities and preferences.
  • Suitable rooms in care settings will be available for individuals, carers and relatives to discuss their own concerns with each other or with staff. When the care setting is in the persons own home the selection of a suitable room will be based on agreement between the practitioner and the individual taking into consideration privacy and the maintenance of dignity.
  • When intimate procedures need to be carried out; the use of chaperones will be considered and offered as appropriate. This role will include acting as an advocate for the individual’s dignity, modesty and privacy,
  • Individuals will be cared for in an environment that actively promotes their privacy and where their dignity and modesty are protected when they are unable to do this for themselves
  • Providers of services will adhere to the national and local NHS and Social Care information sharing principles.
  • Repeated lack of respect could be considered institutional or psychological abuse and a referral under the Safeguarding adults’ policy and procedures or the child protection policy may need to be considered.

1.7 Responsibilities

The responsibility for protecting a person’s privacy and dignity does not lie with anyone individual or group, but with all PCT staff, at any level of the organisation.

1.7.1 Organisational responsibility

  • To ensure that all providers of NHS care have published a declaration before the end of March 2010 to confirm they have virtually eliminated mixed sex accommodation.
  • To ensure that all providers have robust plans in place to continue delivering same sex accommodation.
  • To ensure that after March 2010 reports are sent to the Strategic Health Authority, on an exception basis, when there has been a failure to provide same sex accommodation and the provider has had funds withheld as a result. This is defined as a breach of the standards for same sex accommodation.
  • All breaches must be reported, even if deemed clinically justified. The rationale for clinical justification should be included within the breach report.
  • The PCT will have an internal reporting system in place to allow breaches to be reported by members of the public as well as staff.

1.7.2Director responsibility

  • To lead, promote and champion the privacy and dignity requirements through integrating dignity and respect into governance and service monitoring.
  • To set clear principles for the organisation in relation to dignity and respect, ensuring that measurable standards are met.
  • To ensure that corporate support is made available to assist in the implementation of the privacy and dignity requirements.
  • To ensure that the PCT board is fully briefed regarding the privacy and dignity activity within the organisation.

1.7.3Managers responsibility

  • Implement the principles set out in this policy
  • Ensure that individuals within the team understand their roles and responsibilities with regard to privacy, dignity and respect.
  • Understand and implement specific privacy and dignity activity relevant to their service.
  • Ensure that staff have the tools, resources and skills to promote and deliver services which respect privacy and dignity.
  • Address any local issues related to privacy and dignity, sharing any learning with team members.

1.7.4Individual responsibility

  • Promote the dignity of all people
  • Adhere to the principles set out in this policy
  • Participate in any related training or service development initiatives identified by their manager
  • Comply with the professional code of practice of their governing bodies.
  • Uphold the duty of care and practice within the relevant legislative framework

1.8 Ratification

To be ratified by the Clinical Governance and Patient Safety Forum with minutes noted by Provider Services Committee

1.9 Training

Staff will receive instruction and information regarding privacy, dignity and respect from a number of sources including:

  • PCT policies and procedure documents on induction
  • Line managers
  • Equality and diversity training

1.10 Monitoring and Evaluation

This framework will include privacy and dignity audits, patient satisfaction questionnaires, patient experience feedback including compliments and complaints as detailed in the local procedures related to this policy.

Appendix 1

Equality Impact Assessment Report

Summary of Equality Impact Assessment for:

Date of Assessment:

Main aim of the document / policy / strategy / service:

Outcome of the Equality Impact Assessment Process:

Actions taken and planned as a result of the equality impact assessment, with details of action plan with timescales / review dates as applicable:

Page 1 of 19

Groups / individuals consulted with as part of the impact assessment:

A copy of the full assessment is available upon request by contacting:

Tel 01793 708 757

Fax 01793 708701

Email:

Address: Equality and Diversity Lead Swindon Primary Care Trust

North Swindon District Centre, Thamesdown Drive, SwindonSN25 4AN

If you would like this information in another language of format please ask us.

Part 2 Privacy and Dignity Procedures

Page

2.1Contents13

2.2Introduction14

2.3Development and Implementation14

2.4Standards of practice14

2.4.1 Personal consideration & respect14

2.4.2 Confidentiality15

2.4.3 Privacy Dignity & Modesty16

2.5Availability and distribution18

2.6Monitoring framework18

2.7References Bibliography18

2.2 Introduction

These procedures outline the practical steps adopted by the Swindon Primary Care Trust (PCT) to ensure the privacy and dignity of all individuals receiving services and will provide a framework for all staff working within the organisation.

2.3 Development and implementation

This policy and procedures have been developed by members of the Clinical Governance Team in consultation with Service managers and clinical/professional staff working within the provider services.

Implementation of this policy and associated procedures is the responsibility of all Service Managers

2.4 Standards of Practice

2.4.1 Personal Consideration and Respect

Patients/service users have the right to:

• Be treated as individuals

• Be listened to and have their views taken into account

• Be treated courteously at all times

• Know who is looking after them

• Be cared for in a single sex environment where possible

Examples of good practice to achieve personal consideration and respect include:

  • Staff introduce themselves on initial contact with patients/service users, including phone conversations and state their name and role.
  • Staff should wear identity badges at all times – this may not always be appropriate within some services eg Learning Disability
  • Staff ask each individual how they wish to be addressed e.g. Mrs/Ms and avoid over familiarity, such as the use of colloquial titles e.g. ‘dear’ unless this is acceptable to, and agreed by the patient/service user first.
  • Always establish the acceptability of personal contact (touch) with individuals.
  • Staff working with children and young people in all settings, should promote and protect their individual rights wherever they receive care and treatment. This involves being cared for in a culturally sensitive environment, and ensuring privacy and confidentiality during all episodes of care (RCN 2003).
  • Deal with patient’s/service user’s request for assistance promptly and where there is an unavoidable delay, ensuring an apology is given.
  • Avoid personal conversations with co-workers that exclude the individual e.g. talking to a colleague about the rest of the day’s workload while caring for the patient/service user, or answering your mobile phone. Staff who are required to carry and respond promptly to a work mobile phone should do so sensitively eg ensuring the phone is switched off during meetings with parents and families.
  • Knock before entering a room or attach a notice to curtains saying ‘do not enter’ when the patient is being examined and wait for a reply before opening curtains.
  • Discuss with a patient whether they have any objection to health or social care professionals not directly involved in their care being present during consultations prior to the event so that the patient has the opportunity to refuse.
  • Staff will engage with family members and carers as care partners.
  • Be aware of how body language may be interpreted e.g. standing at the foot of a patient’s bed, with folded arms and avoiding eye contact, may lead a patient to feel that interaction was impersonal and/or intimidating
  • Ensure that any individual who does not speak or understand English or uses British Sign Language (BSL) has access to an interpreter in a timely manner.
  • Ensure all information produced is factual with no jargon or abbreviations.

2.4.2 Confidentiality

Patients/service users have the right to expect that:

• Their consent is requested when their information will be shared with others in order to enable care

Staff must be aware of and follow the principles in the Mental Capacity Act and PCT Policy for Consent to Examination or Treatment to ensure that patients/service users have the mental capacity to give informed consent to the sharing of information.

Under the safeguarding adults policy and procedures, information may need to be shared without the consent of the individual. There may also be times when information is shared against the person’s wishes as within the terms of the safeguarding policy“we must not confuse confidentiality with secrecy – we cannotkeep secrets when it comes to abuse but we have to maintain confidentiality”.