Audit Checklist
Use this checklist to establish whether you provide good standards of privacy and
dignity for your patients, and to identify the steps you still need to take.
You can use the checklist to undertake a full, baseline audit of your hospital or trust,
or to audit individual wards. You should consider the information which the audit
yields alongside other sources of information, such as Essence of Care
Benchmarking, and feedback from local and national surveys of patients and carers
views.
The checklist is a framework which you can adapt to suit your particular
circumstances and needs. Not all of the best practice benchmarks may be relevant
to you. For example, you may not accept emergency admissions, or you may not
have any Nightingale wards within your hospital. You should agree with your audit
team what you mean by terms such as "regularly" and "appropriate". What is
appropriate for you may not be appropriate for others.
Objective 1 - to ensure that appropriate organisational arrangements are in
place to secure good standards of privacy and dignity for hospital patients
Elective patients are accommodated in single rooms, single s*x wards
or single s*x bays/rooms within mixed wards.
Yes
Nightingale
1
wards accommodate either men or women, but not both.
Yes
Patients admitted as an emergency are accommodated in single
rooms, single-s*x wards or single-s*x bays/rooms. Where the use of
mixed-s*x accommodation is unavoidable, the patient is moved to
single-s*x accommodation within 48 hours of their admission.
Yes
Except in an emergency, patients are told in writing prior to admission
if any parts of the ward are shared between men and women.
Yes
Patients know that they may request alternative 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.
Yes
Patients are given privacy during treatment, consultation, or when
receiving personal care
Yes
Personal conversations with patients are conducted away from the
bedside or in such a way that cannot be overheard by other patients
and/or visitors. Conversations with visitors are conducted away from
the bedside in a private room or area.
Yes
Staff prevent patient information from being shared inappropriately, for
example stopping telephone conversations being overheard, computer
screens being viewed or whiteboards being read.
Yes
1
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
2
Staff ensure that patients remain properly clothed/covered when in the
ward and when moving or being moved around the hospital
Yes
Quiet rooms or private spaces are available for use by staff, patients
and visitors.
Yes
Staff manage visiting hours and visitor numbers to ensure patients are
not unduly disturbed by their own or other patients’ visitors
Yes
Staff regularly monitor, evaluate and act upon patient perceptions of
privacy and dignity. Staff respond effectively to concerns expressed
by patients or their visitors about privacy and dignity, and mixed s*x
accommodation.
Yes
Staff education and training promotes the protection 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.
Yes
Nursing care plans encourage specific action to address the individual
patient's privacy and dignity.
Yes
Staff are aware of, and abide by, trust policies and guidelines on
single-s*x 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.
Yes
Objective 2 - to achieve the Patient’s Charter standard for segregated washing
and toilet facilities across the NHS
Separate male and female toilets and washing facilities (other than assisted
facilities) are available within the ward or department and are clearly
labelled.
Yes
Appropriate toilet and washing facilities are located within, or as close as
possible to, the patient’s room or bay.
Yes
To reach toilets and washing facilities, patients do not pass through areas
occupied by members of the opposite s*x. Where patients pass near to
such areas, adequate screening such as opaque glazing or blinds/curtains
at windows and doors is used to prevent embarrassment.
Yes
Toilets and washing facilities are fitted with internal privacy curtains. Staff
ensure these are closed when assisting patients.
Comment: We do not have internal privacy curtains in patient toilets. This
is not an aspect of care we have previously been asked to look at.
No
Toilets and bathrooms are lockable from the inside, with fail-safe entry
mechanisms and nurse-call systems to ensure patient safety.
Yes
Appropriate facilities are provided to uphold the privacy and dignity of
patients who are disabled, whether temporarily (due to their illness or
Yes
3
treatment) or permanently.
Objective 3 - to provide safe facilities for patients in hospitals who are mentally
ill which safeguard their privacy and dignity
Not applicable to the Whittington Hospital
Patients have their own individual rooms or are accommodated in single-
s*x dormitories. Sleeping areas are arranged into separate male and
female zones, to ensure patient safety.
Yes
No
Bedroom doors are lockable from the inside, with fail-safe entry and
observation mechanisms to ensure patient safety.
Yes
No
Separate areas are available within the ward where patients and visitors of
the opposite s*x are not permitted. Staff monitor and control access to
these areas.
Yes
No
Speedy and robust arrangements are in place to deal effectively with
patients, staff or visitors who attack, s*xually abuse or harass others.
Yes
No
Alarm systems, call buttons and other security systems to alert staff to
incidents and emergencies are fitted and working, and accessible to
patients. These are regularly tested.
Yes
No
Local observation policies are devised taking account of guidance
contained in Chapter 18 of the Mental Health Act 1983 Code of Practice.
Yes
No
Patients can choose to have a same-s*x key worker.
Yes
No
Staff working with patients of the opposite s*x are aware of, and abide by,
established policies and protocols to ensure patient safety.
Yes
No
Staff carrying out physical examinations or using restraint on members of
the opposite s*x are of the same gender as the patient, or are
accompanied by a chaperone of the same gender as the patient.
Yes
No
Staff carrying out intimate searches are of the same gender as the patient,
and seek the consent of the patient to undertake the search.
Yes
No
4
Organisational Assessment
(this framework can also be used at ward, department, directorate or hospital level)
Using the information from the checklist, and reflections on your current policies and
practices, identify where on the scale you are in relation to meeting the three
objectives set by the Department of Health.
Where is your organisation positioned on the lines?
Patients experience
Patients experience
poor standards of
X
high standards of
privacy and dignity
privacy and dignity
Toilets and
All toilet and washing
washing facilities
X facilities are fully
are not segregated
segregated
The privacy needs
The privacy needs of
of the mentally ill
the mentally ill are
are not considered
actively promoted
What have you achieved so far?
Our new building opened in 2006, which provides four-bed single s*x rooms with
attached bathrooms and toilet, which has enabled us to move out most of our
medical wards out of our Victorian accommodation. The new building also provides
single s*x accommodation for our acute admission unit.
Our remaining Nightingale medical wards are now completely single s*x.
What is stopping you from achieving the best practice indicator?
Our building stock. Our maternity wards remain in Victorian blocks; a business case
is currently being prepared to improve the standard of the accommodation, which will
require significant additional capital investment. The general wards in our 1990s
building also require upgrading work.
What changes might raise standards of privacy and dignity still further?
Upgrading of general ward accommodation in our 1990s building, which had been
due to start this year (by our PFI partner) but has now been delayed to next year.
Creation of five additional birthing rooms, to relieve pressure in maternity, and
relocating our maternity day unit into larger accommodation during 2008/9 (capital
investment of £1.5 million )
Who do you need to work with to move forward?
Our PFI partner for the parts of the hospital for which they provide facilities and
maintenance support.
NHS Estates/NHS London to approve the business case for our maternity unit.
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