Central and North West London Mental Health NHS Trust

Equality, Human Rights and Privacy Impact Assessment Report

January to December 2010

1 Equality Impact Assessment Report January to December 2010

Equality Impact Assessment (EIA) is a requirement under Equalities and Diversity Law (Race Relations (Amendment) Act 2000, Disability Discrimination Act 2005 and The Equality Act 2006) and comprises a significant element of the requirement of Public Authorities to publish Equality Schemes.

Central and North West London NHS Foundation Trust (CNWL) has a Single Equality Scheme 2008-11 which includes Race, Disability, Gender, Religion or Belief, Sexual orientation and Age.

The Trust has taken a generic approach to Equality Impact Assessment, undertaking a single process to address race/ethnicity, disability, gender, age, sexual orientation and religion/belief. In addition, Human Rights and Privacy considerations are also included within the process of impact assessment. The result is that the Trust now conducts Equality, Human Rights and privacy Impact Assessment (EHRPIA).

Completed assessments are published on the Trust’s public website. They are also published on the Trust’s electronic information system for staff to access.

The EHRPIA process The EHRPIA questionnaire that was initially used was adapted from one originally developed by Brent Council and has evolved since its adoption. A template for completing an Equality Impact Assessment Action Plan was developed in 2006 which not only identifies the adverse impact identified, but the actions to be taken to remedy it, the anticipated timescale, and the manager responsible. All EHRPIAs, including the EHRPIA Action Plan, are counter-signed by a senior line manager. In 2007 it was recognised that it was helpful to ensure that the comments made were side-headed by equalities strand on the EHRPIA form. This improved method of completing the form is now established.

Equality and Human Rights Impact Assessment Policy

In September 2009, the Trust revised its previous Equality Impact Assessment Policy and published an Equality Impact and Human Rights Assessment Policy, extending it to include clearer references to gender identity / transgender, and also to bring Human Rights into consideration.

At time of producing this report, the Policy is being reviewed to ensure that it complies with requirements of the Equality Act 2010 with regard to the considering of Equality issues and having due regard to the general equalities duties.

Equality Impact Assessment Training

During the period of this report the in-house EIA Training workshop has continued to be run for managers and other staff responsible for policy and service development, and this will continue throughout 2010. The Trust’s programme of training has been updated to address the inclusion of gender identity/transgender people and Human Rights.

In addition, the Trust published Human Rights Guidance to promote awareness of the Human Rights agenda in the context of health-care. The Trust has also made the Department of Health’s Human Rights in Healthcare e-learning available for staff and promoted it to all sites and services.

2 Equality and Human Rights Impact Assessment Form

The assessment form has also been updated to include sections to respond to both of these areas, and an additional section was added to provide an opportunity to comment on how a policy/service change might promote equal opportunities, good relations between people from different groups and the elimination of unlawful discrimination. Additionally, the form has been produced in an electronic format so that the structure/content of the form cannot be altered with boxes to complete for all questions and sections within questions. A copy of the form can be found in Appendix 2.

Monitoring of Policies

A Trust-wide database contains Trust policies, details of review dates and whether a policy has been subject to Equality, Human Rights and Privacy Impact Assessment. This will then be utilised in order to identify policies requiring assessment and to give advanced warning of those polices coming up for review.

In order to report on the Equality Impact Assessments completed during 2010, a template has again been used to record the adverse impacts identified, the insights gained from the EIA process, and actions that have been taken in relation to each completed EIA. The full template is included in Appendix 1.

During the course of 2010 the Trust’s Policy on Policies was updated. This policy includes a clear requirement for all policies to have a completed Equality and Human Rights Impact Assessment in order to be ratified for implementation.

Policies and planned developments Equality Impact Assessed

The following is a list of policies/developments that have been subject to the Equality Impact Assessment process in between January and December 2010:

 Admission of Under 18s to an Adult Psychiatric Ward Policy  Change Management Policy  Controlled Access and Egress Policy for In-patient Units  Covert Administration of Medicines Policy  Dress Code Policy  Healthcare Workers Professional Boundaries Policy  Liaison protocol between Acute services and PICU at Park Royal Centre for Mental Health  Learning Disabilities Directorate – Business Plan 2011-14  Management of Intoxicated Patients Policy  Missing Informal Patients Policy  Multi-Agency Public Protection Arrangements (MAPPA) Policy & Procedure  Non-Attendance Policy

3  Nursing Handover Policy for In-patient Wards and Units  Policy on Policies  Prevention and Therapeutic Management of Violence and Aggression Policy  Protected Mealtimes Policy  Relocation of Brent North West Sector Community Mental Health Team  Revision of Disciplinary Policy and Guidance on conducting investigations  Trust Induction  Search Policy  Secondment Policy  Service Line Management Development  Service Move: Kilburn Community Networks and Brent Acute Day Treatment Centre  Volunteering Policy  Well-being Centre and Operational Policy

The results of these are listed in Appendix 1.

Monitoring of Staff and Service Users

One key area identified that needs addressing is that of monitoring. In order to meet legislative requirements with regard to the provision of services, the Trust has instigated systems for recording not only race/ethnicity, gender (including transpeople) and age but also disability, faith/religion and sexual orientation of service users. Data on all six Equalities strands is collected for all CNWL employees.

A new Quality Information System will become operational in 2011 which will include increased capacity to enable monitoring and reporting across all equality characteristics.

Mandatory completion of Equality, Human Rights and Privacy Impact Assessments on New Policies.

In line with the Trust’s updated Policy on Policies, ratified in March 2010, all new policies are expected to have a completed and attached Equality, Human Rights and Privacy Impact Assessment, and all senior managers signing off Trust policies will be expected to ensure that the policy has an attached Equality, Human Rights and Privacy Impact Assessment prior to ratification.

4 Appendix 1 - CNWL Equality Impact Assessment record – January to December 2010

Name of Policy/ Service Equality Date of Equality Adverse impacts or risks of adverse Actions taken to reduce or Impact Assessed Impact impact identified remove identified adverse Assessment impact Admission of Under 18s to an Adult May 2010 None identified Psychiatric Ward Policy

Change Management Policy July 2010

Controlled Access and Egress March 2010 None identified Policy for In-patient Units Covert Administration of Medicines November 2010 Whilst Older Adults service users and Policy service users having a Learning Disability may be more subject to the covert administration of medication subject to an assessment of there mental capacity, this is not regarded as an ‘adverse’ impact’.

It will be dealt with by December 2010 The Project takes into consideration the amendments being made to Datix Project abilities of staff to access the online expectations regarding the use of system, disabled staff will not be the online reporting system. unlawfully discriminated against and equality of opportunity promoted.

Consideration of amendments that may Amendments to policy to note that Display Screen Equipment Policy June 2010 be required for employees with specific amendments can be disabilities. made by the Health and Safety Managers to guidance on a case by case basis.

5 Note in policy that extra consideration may be required when assessing the task for employees with disabilities.

Dress Code Policy January 2010 None identified

Healthcare Workers Professional November 2010 None identified Boundaries Policy Learning Disabilities Directorate – In process at year Easy read version of Business Plan Key sections to be translated into Business Plan 2011-14 end required for service users. Easy-Read format and made available to service users.

Liaison protocol between Acute November 2010 Recognition is made of the nature of a Decisions to admit service users services and PICU at Park Royal PICU with more challenging behaviours with a disability are made on an Centre for Mental Health means disabled people are at a higher individual basis taking their risk. disabled needs and vulnerabilities into account. Whilst studies show that men of Black African- Caribbean ethnicity are more likely to be secluded, audits of the PICU service show that whilst more Black African Caribbean men are admitted they are in fact less likely to be secluded.

The guidance within the policy for safe Manual Handling Policy March 2010 lifting and management of manual Amendments to policy to note that handling may be not suitable for specific amendments can be employees with disabilities. made by the Health and Safety Managers to guidance on a case The guidance differs for men and by case basis. women. The ability to comply with the guidance 6 in the policy may be affected by physical ability dependent on age.

Management of Intoxicated Patients April 2010 None identified Policy Missing Informal Patients Policy March 2010 None identified

Multi-Agency Public Protection March 2010 None identified Arrangements (MAPPA) Policy & Procedure Non-Attendance Policy April 2010 Provision of communication in appropriate languages catered for in Policy. Provision of communication in different formats catered for in Policy. Timing of appoints in relation to faith needs catered for in Policy. Nursing Handover Policy for In- November 2010 None identified patient Wards and Units Policy on Policies February 2010 None identified

Prevention and Therapeutic January 2010 None identified Management of Violence and Aggression Policy Protected Mealtimes Policy November 2010 None identified

Relocation of Brent North West In process at year Location may have an adverse impact Individual risk assessment of Sector Community Mental Health end on service user from specific gender i.e. service users to be carried out to Team women and age i.e. older people as the assess individual risk and suggest new location is situated in an alleyway , the use of other BMHS location this have particular impact in the winter used or appointment booked in months when it is dark after 4 pm. This the morning will also impact on staff within the Staff to leave the building in pairs specific group as mentioned above. if concerned. Ensure that the 7 front gates are locked after 17.00 hrs.

Service users may have difficulties Service users to be informed of accessing new location. change of location both verbally and in writing Assess impact of change. provide service users with travel directions , useful information about new location Provide with more suitable location for meetings , treatment as feasible or if necessary and as appropriate in service users home.

Harlesden has a predominantly Black Service users from North West BME population whereas London Road Sector to be informed of the has a predominantly asian BME characteristics of the locality population. There is a risk that Asian To monitor. population may not access the re- located service to the same proportion at the previous location.

There may be an indirect risk to people To monitor for any adverse of the Hindu, Sikh and other religious impact. groups within the Asian community as a result of the relocation to a predominantly black population.

There may be an indirect risk to people To monitor for any adverse of different sexual orientation e.g. gay impact. service users.

8 Relocation of Kilburn Community February 2010 None identified other than issues Maps, directions and relocation Networks and Brent Acute Day relating to services users being made notices to be provided. Work with Treatment Centre aware of and accessing the new service individual service users to map location. the journey.

Revision of Disciplinary Policy and 19 January 2010 None identified Guidance on conducting investigations Search Policy January 2010 None identified

Secondment Policy 19 January 2010 None identified

Service Line Management Possible reductions in staff could affect To be taken account of within Development – advisory June 2010 particular ethnic groups. planning assessment Less clear accountability and possible To be taken account of within reduced linkage to Borough-based planning and measures to be communities /networks impacting on included to preserve Borough- partnership working, consultation, based community linkagesand accountability to local populations and local accountability collaborative relationships in general.

Possible reduced access for disabled To be taken account of within people to services where there are planning and measures to be amalgamations /rationalisations leading included to ensure reasonable to greater travel requirements adjustment options are available

Trust Induction 4 January 2010 None identified

Volunteering Policy April 2010 None identified

Well-being Centre and Operational Undertaken in None identified Policy (Hillingdon) 2010, signed off Jan 2011 9 Appendix 2 – Equality Impact Assessment Form

Equality and Human Rights Impact Assessment Form

This form is protected. You can only complete the fields that are shaded. They will expand as you type so that you are not limited to how much you write. You can move between the fields using the cursor up and down keys.

Screening assessment 1.What is the name of the service / policy / procedure / project being assessed

2.Briefly describe the aim of the service /policy /procedure / Trust function that is being Impact Assessed. What needs or duties is it designed to meet? What are its intended outcomes?

3. If this service /policy /procedure / Trust function has no relevance for Equalities or human rights considerations, please give your reasoning below and sign.

There is no relevance for equalities or human rights considerations

Manager undertaking the screening assessment Name Designation: Date To be countersigned by the Senior Manager, i.e. Service Head, Line Manager, Director, as appropriate Name Designation: Date * *

10 Full assessment

4. How does the policy / procedure / protocol / service development:

 Contribute to eliminating unlawful discrimination?  Contribute to promoting equality of opportunity?  Contribute to promoting good relations between people of different groups?  Encourage respect for human rights?

5a.Is there any evidence that the service / policy could affect some groups of people (race/ethnicity, disability, gender (including transgender people or people undergoing gender reassignment), age, faith/religion, sexual orientation) disproportionately? Is there reason to believe that the service / policy may have different outcomes for different groups? Is there an adverse impact? What are the reasons for this adverse impact? Please comment under each of the side headings below. Race/ethnicity:

Disability:

Gender (including transgender and gender reassignment):

Religion or Belief

Sexual orientation

5b.Is there any evidence that the service / policy is at risk of unlawfully restricting an individual’s human rights?

6. Please describe the evidence you have used to make your judgement in 5a and 5b. What existing data for example (quantitative or qualitative) have you used to form your judgement? Race/ethnicity: 11

Disability:

Gender (including transgender and gender reassignment):

Religion or Belief

Sexual orientation

Human Rights

7. Have you consulted with the public / staff / service users / carers as part of your assessment? Who have you consulted? What method did you use? What were the results of the consultation and what have you done with them (i.e. how have you used the information gathered as part of the consultation?)

8. Have you published results of the consultation? If so, where?

9. Is there public concern (in the local or national media for example) that this function / policy / service is being operated in a discriminatory manner? How have you taken this into account with regard to consultation, publishing the results of that consultation and in the policy or service development that is subject to this EHRIA?

10. If, in your judgement, the proposed service /policy / procedure does have an adverse impact or is at risk of unlawfully restricting Human Rights, can that impact be justified? - You need to think whether the proposed service / policy / procedure will have a positive or negative effect on the:  Elimination of unlawful discrimination 12  Promotion of equal opportunity  Promotion of good relations between people of different groups  Ensuring respect for human rights

11. If the impact cannot be justified, how do you intend to deal with it?

12. Provide information on how you intend to monitor in the future

Equality and Human Rights Impact Assessment Action Plan

The following actions will be undertaken as a result of the Equality and Human Rights Impact Assessment to address identified adverse impact:

Adverse impact Action to be taken Timescale Responsible manager identified

To be signed by the manager undertaking the full assessment Name Designation: Date To be countersigned by the Senior Manager, i.e. Service Head, Line Manager, Director, as appropriate Name Designation: Date